A pilot recruitment strategy to enhance ethical and equitable access to Covid-19 pediatric vaccine trials.

BACKGROUND/AIMS: The SARS-CoV-2 pandemic disproportionately impacted communities with lower access to health care in the United States, particularly before vaccines were widely available. These same communities are often underrepresented in clinical trials. Efforts to ensure equitable enrollment of participants in trials related to treatment and prevention of Covid-19 can raise concerns about exploitation if communities with lower access to health care are targeted for recruitment. METHODS: To enhance equity while avoiding exploitation, our site developed and implemented a three-part recruitment strategy for pediatric Covid-19 vaccine studies. First, we publicized a registry for potentially interested participants. Next, we applied public health community and social vulnerability indices to categorize the residence of families who had signed up for the registry into three levels to reflect the relative impact of the pandemic on their community: high, medium, and low. Finally, we preferentially offered study participation to interested families living in areas categorized by these indices as having high impact of the Covid-19 pandemic on their community. RESULTS: This approach allowed us to meet goals for study recruitment based on public health metrics related to disease burden, which contributed to a racially diverse study population that mirrored the surrounding community demographics. While this three-part recruitment strategy improved representation of minoritized groups from areas heavily impacted by the Covid-19 pandemic, important limitations were identified that would benefit from further study. CONCLUSION: Future use of this approach to enhance equitable access to research while avoiding exploitation should test different methods to build trust and communicate with underserved communities more effectively.

Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index.

Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.

Centiles for the shock index among injured children in the prehospital setting.

OBJECTIVE: The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS: We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS: We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION: We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.

Disparities in Telemedicine Use Among Children Seen in Surgical Clinics During the COVID-19 Pandemic: Experience of One Tertiary Care Freestanding Children's Hospital.

Background: Telemedicine use dramatically increased during the COVID-19 pandemic. However, the effects of telemedicine on pre-existing disparities in pediatric surgical access have not been well described. We describe our center's early experience with telemedicine and disparities in patients' access to outpatient surgical care. Methods: A retrospective study of outpatient visits within all surgical divisions from May to December 2020 was conducted. We assessed the rates of scheduled telemedicine visits during that period, as well as the rate of completing a visit after it has been scheduled. Descriptive and logistic regression analyses were used to test for associations between these rates and patient characteristics. Results: Over the study period, 109,601 visits were scheduled. Telemedicine accounted for 6.1% of all visits with lower cancellation rates than in-person visits (26.9% vs. 34.7%). More scheduled telemedicine encounters were observed for older patients, White, English speakers, those with private insurance, and those living in rural areas. Lower odds of telemedicine visit completion were observed among patients with public insurance (odds ratio [OR] 0.7, 95% confidence interval [CI] 0.64-0.77), Spanish language preference (OR 0.84, 95% CI 0.72-0.97), and those living in rural areas (OR 0.73, 95% CI 0.64-0.84). In contrast, higher odds of telemedicine visit completion were associated with a higher Social Deprivation Index score (OR 1.41, 95% CI 1.27-1.58). Telemedicine visit completion was also associated with increasing community-level income and distance from the hospital. Conclusions: Telemedicine use for outpatient surgical care was generally low during the peak of the pandemic, and certain populations were less likely to utilize it. These findings call for further action to bridge gaps in telemedicine use.

Randomised feasibility trial of a virtual intervention to address infant car seat misuse.

BACKGROUND: Serious car seat installation errors occur at high rates in infants and children. These errors significantly increase the risk of child injury in a motor vehicle crash, and few interventions have addressed the challenge longitudinally. METHODS: This was a pilot randomised controlled feasibility trial of virtual car seat safety checks for caregivers of newborns recruited from an urban newborn nursery. The control (enhanced usual care (EUC)) group received an in-person car seat check as a newborn and virtual check at 9 months. The intervention group received two additional virtual checks at 3 and 6 months. Installation and infant positioning errors were documented and corrected by a child passenger safety technician (CPST). We measured feasibility and acceptability by tracking caregiver and CPST challenges, and caregiver retention. Group differences were tested for statistical significance using χ2 or Fisher's exact test for categorical variables, and two sample t-tests for continuous variables. RESULTS: 33 caregivers were randomised to the EUC and 28 to the intervention group. Virtual checks were feasible, with variable participation levels at each quarter. Wi-Fi and app challenges noted in 30%. There was satisfaction with the virtual car seat checks. At baseline, car seat installation and infant positioning errors occurred at equal frequency, and at 9 months the intervention group had a significantly lower mean proportion than the EUC group in all categories of errors. In summary, virtual seat checks are feasible and the optimal timing of repeat checks requires additional study. A larger study is needed to further evaluate the effect of longitudinal virtual checks on errors.

Pediatric Telehealth Access and Utilization in Chicago During the First Year of the COVID-19 Pandemic.

Background: The COVID-19 pandemic demanded rapid development of telemedicine services for pediatric care and highlighted disparities for marginalized communities. Objective: To understand the demographic characteristics of patients with completed and incomplete telemedicine visits at Ann and Robert H. Lurie Children's Hospital of Chicago. Methods: This was a cross-sectional retrospective analysis of telemedicine visits for patients <25 years old scheduled between March 21, 2020, and March 17, 2021. We examined visit outcomes and compared outcomes by race/ethnicity, language, and payer using logistic regression. Geographic information system mapping and linear regression were used to examine the relationship between incomplete visits and broadband access within Cook County. Results: A total of 13,655 eligible video visits were scheduled for children within 147 ZIP codes during the study time frame. Patient characteristics included median age 9 years, 53% female, 42% non-Latinx White, 31% Latinx, 13% non-Latinx Black, 11% non-Latinx other, and 3% declined/unknown. Preferred language was 89% English, 10% Spanish, and 1% other. Payer was 56% private, 43% public, and <1% other/self-pay. Overall, 86% video visits were completed, 7% cancelled, and 7% no-show with significant variation by patient demographic. Odds of incomplete visits were higher for Latinx patients (odds ratio [OR] 1.93) and non-Latinx Black patients (OR 2.33) than for non-Latinx White patients, patients with preferred language other than English (OR 1.53), and patients not privately insured (OR 1.89). Incomplete visit rates and broadband access were inversely related. Conclusion: System and policy solutions are needed to ensure equitable access and address disparities in incomplete telemedicine visits for marginalized populations in urban areas with lower broadband.

Low-Resource Emergency Department Visits for Children With Complex Chronic Conditions.

OBJECTIVE: Reducing emergency department (ED) use in children with complex chronic conditions (CCC) is a national health system priority. Emergency department visits with minimal clinical intervention may be the most avoidable. We assessed characteristics associated with experiencing such a low-resource ED visit among children with a CCC. METHODS: A retrospective study of 271,806 ED visits between 2014 and 2017 among patients with a CCC in the Pediatric Health Information System database was performed. The main outcome was a low-resource ED visit, where no medications, laboratory, procedures, or diagnostic tests were administered and the patient was not admitted to the hospital. χ2 Tests and generalized linear models were used to assess bivariable and multivariable relationships of patients' demographic, clinical, and health service characteristics with the likelihood of a low- versus higher-resource ED visit. RESULTS: Sixteen percent (n = 44,111) of ED visits among children with CCCs were low-resource. In multivariable analysis, the highest odds of experiencing a low- versus higher-resource ED visit occurred in patients aged 0 year (vs 16+ years; odds ratio [OR], 3.9 [95% confidence interval {CI}, 3.7-4.1]), living <5 (vs 20+) miles from the ED (OR, 1.7 [95% CI, 1.7-1.8]), and who presented to the ED in the day and evening versus overnight (1.5 [95% CI, 1.4-1.5]). CONCLUSIONS: Infant age, living close to the ED, and day/evening-time visits were associated with the greatest likelihood of experiencing a low-resource ED visit in children with CCCs. Further investigation is needed to assess key drivers for ED use in these children and identify opportunities for diversion of ED care to outpatient and community settings.

Pediatric Emergency Medicine Physicians' Perspectives on Emergency Care of Children With Medical Complexity: A Multi-institution Mixed-Methods Assessment.

OBJECTIVE: Children with medical complexity (CMC) compose 1% of the pediatric population but account for 20% of pediatric emergency department (ED) visits. Previous descriptions of challenges and interventions to ensure quality of care are limited. Our objective was to elicit pediatric emergency medicine (PEM) physicians' perspectives on challenges and opportunities for improvement of emergency care of CMC, with a focus on emergency information forms (EIFs). METHODS: We conducted a web-based survey of PEM physicians participating the American Academy of Pediatrics Section on Emergency Medicine Survey listserv. The survey was designed using an expert panel, and subsequently piloted and revised to an 18-item survey. Data were analyzed with descriptive statistics. RESULTS: One hundred fifty-one of 495 respondents (30%) completed the survey. Most respondents (62.9%) reported caring for >10 CMC per month. Whereas overall medical fragility and time constraints were major contributors to the challenges of caring for CMC in the ED, communication with known providers and shared care plans were identified as particularly helpful. Most respondents did not report routine use of EIFs. Anticipated emergencies/action plan was deemed the most important component of EIFs. CONCLUSIONS: Most PEM physicians view the care for CMC in the ED as challenging despite practicing in high-resource environments. Further research is needed to develop and implement strategies to improve care of CMC in the ED. Understanding experiences of providers in general ED settings is also an important next step given that 80% of CMC present for emergency care outside of major children's hospitals.

Characteristics of Children Who Deteriorate After Transport and Associated Preadmission Factors.

OBJECTIVE: The incidence of deterioration and associated characteristics are largely unknown for children transported for admission from referring emergency departments (EDs) to general inpatient units. This study describes this population and identifies associated preadmission characteristics. METHODS: This single-center cohort study included children ≤ 18 years old transferred from an ED and directly admitted to general inpatient units from 2016 to 2019. Deterioration was defined as 1 or more of the following occurring within 24 hours of admission: rapid response team activation, transfer to the intensive care unit (ICU), or cardiac or respiratory arrest. ICU transfer was the secondary outcome. Logistic regression was performed. RESULTS: One thousand nine hundred eighty-eight patients were included; the median age was 4.2 years, 53.9% were male, and 44.1% had respiratory diagnoses. Deterioration occurred in 135 (6.8%) children overall and in 10.1% of children with respiratory complaints. Deterioration was associated with ≥ 2 complex chronic conditions (adjusted odds ratio [aOR] = 2.09; 95% confidence interval [CI], 1.04-4.19) and a longer stabilization time (per 10 minutes) (aOR = 1.17; 95% CI, 1.01-1.36). ICU transfer was associated with ≥ 2 complex chronic conditions (aOR = 2.33; 95% CI, 1.13-4.80), supplemental oxygen via nasal cannula (aOR = 2.13; 95% CI, 1.18-3.85), and nebulizer treatment (aOR = 2.77; 95% CI, 1.21-6.35). CONCLUSION: Deterioration was experienced by 7% of children admitted to a general unit, with the majority having respiratory complaints. Transport teams should consider the potential for increased risk of deterioration among children with respiratory disease, multiple complex chronic conditions, and a nasal cannula or nebulizer therapy. The clinical significance of marginally longer stabilization times is unclear and warrants further investigation.

Growth and changes in the pediatric medical subspecialty workforce pipeline.

BACKGROUND: To inform discussions of pediatric subspecialty workforce adequacy and characterize its pipeline, we examined trends in first-year fellows in the 14 American Board of Pediatrics (ABP)-certified pediatric medical subspecialties, 2001-2018. METHODS: Data were obtained from the ABP Certification Management System. We determined, within each subspecialty, the annual number of first-year fellows. We assessed for changes in the population using variables available throughout the study period (gender, medical school location, program region, and program size). We fit linear trendlines and calculated χ2 statistics. RESULTS: The number of first-year pediatric medical subspecialty fellows increased from 751 in 2001 to 1445 in 2018. Fields with the growth of 3 or more fellows per year were Cardiology, Critical Care, Emergency Medicine, Gastroenterology, Neonatology, and Hematology Oncology (P value <0.05 for all). The number of fellows entering Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology increased at a rate of 0.5 fellows or fewer per year. Female American Medical Graduates represented the largest and growing proportions of several subspecialties. Distribution of programs by region and size were relatively consistent over time, but varied across subspecialties. CONCLUSIONS: The number of pediatricians entering medical subspecialty fellowship training is uneven and patterns of growth differ between subspecialties. IMPACT: The number of individuals entering fellowship training has increased between 2001 and 2018. Growth in the number of first-year fellows is uneven. Fields with the greatest growth: Critical Care, Emergency Medicine, and Neonatology. Fields with limited growth: Adolescent Medicine, Child Abuse, Infectious Disease, and Nephrology. Concerns about the pediatric medical subspecialty workforce are not explained by the number of individuals entering the fellowship.

Parental COVID-19 vaccine hesitancy for children: vulnerability in an urban hotspot.

OBJECTIVE: To compare hesitancy toward a future COVID-19 vaccine for children of various sociodemographic groups in a major metropolitan area, and to understand how parents obtain information about COVID-19. METHODS: Cross-sectional online survey of parents with children < 18 years old in Chicago and Cook County, Illinois, in June 2020. We used logistic regression to determine the odds of parental COVID-19 vaccine hesitancy (VH) for racial/ethnic and socioeconomic groups, controlling for sociodemographic factors and the sources where parents obtain information regarding COVID-19. RESULTS: Surveys were received from 1702 parents and 1425 were included in analyses. Overall, 33% of parents reported VH for their child. COVID-19 VH was higher among non-Hispanic Black parents compared with non-Hispanic White parents (Odds Ratio (OR) 2.65, 95% Confidence Interval (CI): (1.99-3.53), parents of publicly insured children compared with privately insured (OR 1.93, (1.53-2.42)) and among lower income groups. Parents receive information about COVID-19 from a variety of sources, and those who report using family, internet and health care providers as information sources (compared to those who don't use each respective source) had lower odds of COVID-19 VH for their children. CONCLUSIONS: The highest rates of hesitancy toward a future COVID-19 vaccine were found in demographic groups that have been the most severely affected by the pandemic. These groups may require targeted outreach efforts from trusted sources of information in order to promote equitable uptake of a future COVID-19 vaccine.

Engagement in research among pediatric subspecialists at the time of enrollment in maintenance of certification, 2009-2016.

BACKGROUND: Amid concerns about the pediatrician-scientist workforce, we hypothesized that declining numbers of pediatric subspecialists devote at least 25% of their professional time to research with fewer younger and female pediatricians engaged in research over the study period. METHODS: Board-certified pediatricians enrolling online in the American Board of Pediatrics (ABP's) Maintenance of Certification (MOC) program October 2009 through 2016 were invited to complete a survey with questions about the allocation of their professional time. Responses from individuals in the 14 ABP-certified subspecialties were analyzed. The number and proportions of respondents devoting 25-49% and 50% or more of professional time to research were calculated over time. Age and gender were also examined. RESULTS: We analyzed 21,367 responses over 8 years. A small number of pediatric subspecialists engaged in research with 5.2-6.7% devoting 25-49% and 5.6-8.4% at least 50% of their professional time to research across subspecialties. There was no discernable increase or decrease over time or pattern by age or gender. CONCLUSION: Less than 10% of pediatric medical subspecialists devote at least 50% of their professional time to research. Efforts to promote research among pediatric subspecialists have not increased the size of the population that reports engaging in research at this level.

Baseline Performance of Real-World Clinical Practice Within a Statewide Emergency Medicine Quality Network: The Michigan Emergency Department Improvement Collaborative (MEDIC).

STUDY OBJECTIVE: Large-scale quality and performance measurement across unaffiliated hospitals is an important strategy to drive practice change. The Michigan Emergency Department Improvement Collaborative (MEDIC), established in 2015, has baseline performance data to identify practice variation across 15 diverse emergency departments (EDs) on key emergency care quality indicators. METHODS: MEDIC is a unique physician-led partnership supported by a major third-party payer. Member sites contribute electronic health record data and trained abstractors add supplementary data for eligible cases. Quality measures include computed tomography (CT) appropriateness for minor head injury, using the Canadian CT Head Rule for adults and Pediatric Emergency Care Applied Network rules for children; chest radiograph use for children with asthma, bronchiolitis, and croup; and diagnostic yield of CTs for suspected pulmonary embolism. Baseline performance was established with statistical process control charts. RESULTS: From June 1, 2016, to October 31, 2017, the MEDIC registry contained 1,124,227 ED visits, 23.2% for children (<18 years). Overall baseline performance included the following: 40.9% of adult patients with minor head injury (N=11,857) had appropriate CTs (site range 24.3% to 58.6%), 10.3% of pediatric minor head injury cases (N=11,183) exhibited CT overuse (range 5.8% to 16.8%), 38.1% of pediatric patients with a respiratory condition (N=18,190) received a chest radiograph (range 9.0% to 62.1%), and 8.7% of pulmonary embolism CT results (N=16,205) were positive (range 7.5% to 14.3%). CONCLUSION: Performance varied greatly, with demonstrated opportunity for improvement. MEDIC provides a robust platform for emergency physician engagement across ED practice settings to improve care and is a model for other states.

Timing and Stability of Fellowship Choices during Pediatric Residency: A Longitudinal Survey.

OBJECTIVES: To determine, among pediatric residents, the timing and stability of decisions to pursue fellowship training and select a specific subspecialty, which can be used to inform strategies to better match the distribution of pediatric subspecialist with the needs of children. STUDY DESIGN: A longitudinal survey administered with the General Pediatrics In-training Exam to pediatric residents in the US and Canada, 2010-2014. The study included residents who responded in each of their first 3 years of residency and indicated plans to enter fellowship or matriculated, 2013-2016, into 1 of the 14 medical subspecialty fellowships for which the American Board of Pediatrics grants a certificate. Descriptive and χ2 statistics were calculated. RESULTS: Of the 7580 residents who completed 3 annual surveys (response rate 99%) 4963 (65.5%) indicated plans to pursue fellowship training and 2843 (37.5%) matriculated into fellowship. Residents who did not enter fellowship were in smaller residency programs and programs with less interest in fellowship among interns. Most residents who matriculated into fellowship (68.4%) planned to do so as interns and maintained that plan throughout residency. In contrast, 22.7% had selected a specific subspecialty as interns. Fellowship decisions were made later in residency by female residents, American Medical Graduates, and residents in programs where <50% of interns planned to pursue fellowship training. Timing and stability of decisions varied across subspecialty fields. CONCLUSIONS: Understanding the timing of pediatric medical subspecialty fellowship decisions could be used to shape medical education and, ultimately, the pediatric workforce.

Variation in Part-Time Work among Pediatric Subspecialties.

OBJECTIVE: To assess the part-time workforce and average hours worked per week among pediatric subspecialists in the 15 medical subspecialties certified by the American Board of Pediatrics. STUDY DESIGN: We examined data from pediatric subspecialists who enrolled in Maintenance of Certification with the American Board of Pediatrics from 2009 to 2015. Data were collected via an online survey. Providers indicated whether they worked full time or part time and estimated the average number of hours worked per week in clinical, research, education, and administrative tasks, excluding time on call. We calculated and compared the range of hours worked by those in full- and part-time positions overall, by demographic characteristics, and by subspecialty. RESULTS: Overall, 9.6% of subspecialists worked part time. There was significant variation in part-time employment rates between subspecialties, ranging from 3.8% among critical care pediatricians to 22.9% among developmental-behavioral pediatricians. Women, American medical graduates, and physicians older than 70 years of age reported higher rates of part-time employment than men, international medical graduates, and younger physicians. There was marked variation in the number of hours worked across subspecialties. Most, but not all, full-time subspecialists reported working at least 40 hours per week. More than one-half of physicians working part time in hematology and oncology, pulmonology, and transplant hepatology reported working at least 40 hours per week. CONCLUSIONS: There are unique patterns of part-time employment and hours worked per week among pediatric medical subspecialists that make simple head counts inadequate to determine the effective workforce. Our findings are limited to the 15 American Board of Pediatrics-certified medical subspecialties.

Pediatric Emergency Department Resource Utilization among Children with Primary Care Clinic Contact in the Preceding 2 Days: A Cross-Sectional Study.

OBJECTIVES: To characterize pediatric patient contacts with their primary care clinic in the 2 days preceding a visit to the emergency department (ED) and explore how the type of clinic contact relates to ED resource use. STUDY DESIGN: We conducted a retrospective chart review of 368 pediatric ED visits in the first 7 days of each month, from September 2012 to August 2013. Visits were included if the family contacted their child's general pediatric clinic in the study health system in the 2 days preceding the ED visit. Descriptive statistics were calculated. Primary outcomes were ED resource use (tests, treatments) and disposition (admission or discharge). Outcomes by type of clinic contact were compared with χ2 statistics. RESULTS: Of 1116 records with ED visits in the 12 study weeks extracted from the electronic medical record, 368 ED visits met inclusion criteria. Most ED visits followed a single clinic contact (78.8%). Of the 474 clinic contacts, 149 were in-person visits, 216 phone calls when clinic was open, and 109 phone calls when clinic was closed. ED visits that followed an in-person clinic contact with advice to go to the ED had significantly greater rates of testing and admission than those advised to go to the ED after phone contact and those never advised to go to the ED. CONCLUSIONS: In-person clinic visits with advice to go to the ED were associated with the greatest ED resource use. Limitations include a study of a single health system without a uniform process for triaging patients to the ED across clinics.

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

OBJECTIVES: To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models. STUDY DESIGN: We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy. RESULTS: For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals. CONCLUSIONS: We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.

Healthcare utilization and spending by children with cancer on Medicaid.

BACKGROUND: Children with cancer are a unique patient population with high resource, complex healthcare needs. Understanding their healthcare utilization could highlight areas for care optimization. PROCEDURE: We performed a retrospective, cross-sectional analysis of the 2014 Truven Marketscan Medicaid Database to explore clinical attributes, utilization, and spending among children with cancer who were Medicaid enrollees. Eligible patients included children (ages 0-18 years) with cancer (Clinical Risk Group 8). Healthcare utilization and spending (per member per month, PMPM) were assessed overall and across specific healthcare services. RESULTS: Children with cancer (n = 5,405) represent less than 1% of the 1,516,457 children with medical complexity in the dataset. Children with cancer had high services use: laboratory/radiographic testing (93.0%), outpatient specialty care (83.4%), outpatient therapy/treatment (53.4%), emergency department (43.7%), hospitalization (31.5%), home healthcare (9.5%). PMPM spending for children with cancer was $3,706 overall and $2,323 for hospital care. CONCLUSION: Children with cancer have high healthcare resource use and spending. Differences in geographic distribution of services for children with cancer and the trajectory of spending over the course of therapy are areas for future investigation aimed at lowering costs of care without compromising on health outcomes.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury.

OBJECTIVE: To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN: Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS: There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS: Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.