Urban-Rural Residence and Child Physical Abuse Hospitalizations: A National Incidence Study.

OBJECTIVE: To determine if child physical abuse hospitalization rates vary across urban-rural regions overall and after accounting for race/ethnicity and poverty demographics. STUDY DESIGN: This was a retrospective cross-sectional study of black, Hispanic, and non-Hispanic white children <5 years of age living in all US counties. US counties were classified as central metro, fringe/small metro, and rural. Incidence rates were calculated using child physical abuse hospitalization counts from the 2012 Kids' Inpatient Database and population statistics from the 2012 American Community Survey. Counties' race/ethnicity demographics and percent of children living in poverty were used to adjust rates. RESULTS: We identified 3082 child physical abuse hospitalizations occurring among 18.2 million children. Neither crude nor adjusted overall rates of child physical abuse hospitalizations varied significantly across the urban-rural spectrum. When stratified by race/ethnicity, crude child physical abuse hospitalization rates decreased among black children 29.1% (P = .004) and increased among white children 25.6% (P = .001) from central metro to rural counties. After adjusting for poverty, only rates among black children continued to vary significantly, decreasing 34.8% (P = .001) from central metro to rural counties. Rates were disproportionately higher among black children compared with white children and their disproportionality increased with population density, even after poverty adjustment. Rates among Hispanic children were disproportionately lower compared with white children in nearly all urban-rural categories. CONCLUSIONS: Our results suggest that urban black children have unique exposures, outside of poverty, increasing their risk for child physical abuse hospitalization. Identifying and addressing these unique urban exposures may aid in reducing black-white disproportionalities in child physical abuse.

Pathways to Publication in Pediatric Hospital Medicine Educational Research.

OBJECTIVES: Dissemination of rigorous, innovative educational research is key to inform best practices among the global medical education community. Although abstract presentation at professional conferences is often the first step, journal publication maximizes impact. The current state of pediatric hospital medicine (PHM) educational scholarship dissemination via journal publication has not been well described. To describe educational research dissemination after PHM conference abstract submission, we identified the publication rate, median time to publication, and median publishing journal impact factor of abstracts submitted over 4 years. METHODS: Abstract data were obtained from the 2014-2017 PHM conferences and organized by presentation type (oral, poster, rejected). PubMed, MedEdPORTAL, and Google Scholar were queried for abstract publication evidence. We used logistic regression models, Kaplan-Meier survival curves and Kruskal-Wallis tests to determine the association of presentation type with the odds of publication, time to publication, and publishing journal impact factors. RESULTS: Of 173 submitted educational research abstracts, 56 (32%) were published. Oral abstracts had threefold greater and fivefold greater odds of publication compared to poster and rejected abstracts, respectively (odds ratio 3.2; 95% confidence interval 1.3-8.0; P = .011; odds ratio 5.2; 95% confidence interval 1.6-16.7; P = .003). Median time to publication did not differ between presentation types. The median journal impact factor was >2 times higher for published oral and poster abstracts than published rejected abstracts. CONCLUSIONS: Because abstract acceptance and presentation type may be early indicators of publication success, abstract submission to the PHM conference is a reasonable first step in disseminating educational scholarship.

Current Practices and Perspectives on Peer Observation and Feedback: A National Survey.

OBJECTIVE: Peer observation and feedback (POF) is the direct observation of an activity performed by a colleague followed by feedback with the goal of improved performance and professional development. Although well described in the education literature, the use of POF as a tool for development beyond teaching skills has not been explored. We aimed to characterize the practice of POF among pediatric hospitalists to explore the perceived benefits and barriers and to identify preferences regarding POF. METHODS: We developed a 14-item cross-sectional survey regarding divisional expectations, personal practice, perceived benefits and barriers, and preferences related to POF. We refined the survey based on expert feedback, cognitive interviews, and pilot testing, distributing the final survey to pediatric hospitalists at 12 institutions across the United States. RESULTS: Of 357 eligible participants, 198 (56%) responded, with 115 (58%) practicing in a freestanding children's hospital. Although 61% had participated in POF, less than one half (42%) reported divisional POF expectation. The most common perceived benefits of POF were identifying areas for improvement (94%) and learning about colleagues' teaching and clinical styles (94%). The greatest perceived barriers were time (51%) and discomfort with receiving feedback from peers (38%), although participation within a POF program reduced perceived barriers. Most (76%) desired formal POF programs focused on improving teaching skills (85%), clinical management (83%), and family-centered rounds (82%). CONCLUSIONS: Although the majority of faculty desired POF, developing a supportive environment and feasible program is challenging. This study provides considerations for improving and designing POF programs.

Sexually Transmitted Infection Testing in Adolescents: Current Practices in the Hospital Setting.

PURPOSE: Adolescents are disproportionately affected by sexually transmitted infections (STIs), and evidence supports expanding sexual health services to the hospital setting. Because STI testing practices in the hospital setting are poorly understood, we sought to describe current STI testing practices among adolescents seen in children's hospitals. METHODS: We performed a retrospective analysis of adolescents (14-18 years old) from 45 children's hospitals in 2015-2016, excluding visits with a billing code for sexual abuse/assault. We calculated rates of STI testing and investigated differences in STI testing by patient and hospital characteristics using generalized linear mixed modeling. RESULTS: Of the 541,714 adolescent encounters, 59,158 (10.9%) underwent STI testing. After adjusting for demographic characteristics, those with an STI test were more likely to be female (adjusted odds ratio [aOR] 1.61; 95% confidence interval [CI] 1.58-1.64), of non-Hispanic black race/ethnicity (aOR 1.20; 95% CI 1.17-1.23), or from the lowest median household income quartile (aOR 1.21; 95% CI 1.17-1.24). There was substantial inter-hospital variation in adjusted rates of STI testing (3%-24%), but strong correlation was observed between STI testing rates in the ED and inpatient settings within individual hospitals (adjusted R2 .99). CONCLUSIONS: Only one in ten adolescents seen in children's hospitals underwent STI testing with wide variation in testing patterns across hospitals. There are critical opportunities to increase adolescent STI testing in this setting. Our findings highlight potential disparities in STI testing rates and patterns that warrant further exploration from the patient, provider, and health system perspective.

Potential Opportunities for Prevention or Earlier Diagnosis of Child Physical Abuse in the Inpatient Setting.

OBJECTIVES: To compare rates of previous inpatient visits among children hospitalized with child physical abuse (CPA) with controls as well as between individual abuse types. METHODS: In this study, we used the Pediatric Health Information System administrative database of 44 children's hospitals. Children <6 years of age hospitalized with CPA between January 1, 2011, and September 30, 2015, were identified by discharge codes and propensity matched to accidental injury controls. Rates for previous visit types were calculated per 10 000 months of life. χ2 and Poisson regression were used to compare proportions and rates. RESULTS: There were 5425 children hospitalized for CPA. Of abuse and accident cases, 13.1% and 13.2% had a previous inpatient visit, respectively. At previous visits, abused children had higher rates of fractures (rate ratio [RR] = 3.0 times; P = .018), head injuries (RR = 3.5 times; P = .005), symptoms concerning for occult abusive head trauma (AHT) (eg, isolated vomiting, seizures, brief resolved unexplained events) (RR = 1.4 times; P = .054), and perinatal conditions (eg, prematurity) (RR = 1.3 times; P = .014) compared with controls. Head injuries and symptoms concerning for occult AHT also more frequently preceded cases of AHT compared with other types of abuse (both P < .001). CONCLUSIONS: Infants hospitalized with perinatal-related conditions, symptoms concerning for occult AHT, and injuries are inpatient populations who may benefit from abuse prevention efforts and/or risk assessments. Head injuries and symptoms concerning for occult AHT (eg, isolated vomiting, seizures, and brief resolved unexplained events) may represent missed opportunities to diagnose AHT in the inpatient setting; however, this requires further study.

Association of Income Inequality With Pediatric Hospitalizations for Ambulatory Care-Sensitive Conditions.

Importance: The level of income inequality (ie, the variation in median household income among households within a geographic area), in addition to family-level income, is associated with worsened health outcomes in children. Objective: To determine the influence of income inequality on pediatric hospitalization rates for ambulatory care-sensitive conditions (ACSCs) and whether income inequality affects use of resources per hospitalization for ACSCs. Design, Setting, and Participants: This retrospective, cross-sectional analysis used the 2014 State Inpatient Databases of the Healthcare Cost and Utilization Project of 14 states to evaluate all hospital discharges for patients aged 0 to 17 years (hereafter referred to as children) from January 1 through December 31, 2014. Exposures: Using the 2014 American Community Survey (US Census), income inequality (Gini index; range, 0 [perfect equality] to 1.00 [perfect inequality]), median household income, and total population of children aged 0 to 17 years for each zip code in the 14 states were measured. The Gini index for zip codes was divided into quartiles for low, low-middle, high-middle, and high income inequality. Main Outcomes and Measures: Rate, length of stay, and charges for pediatric hospitalizations for ACSCs. Results: A total of 79 275 hospitalizations for ACSCs occurred among the 21 737 661 children living in the 8375 zip codes in the 14 included states. After adjustment for median household income and state of residence, ACSC hospitalization rates per 10 000 children increased significantly as income inequality increased from low (27.2; 95% CI, 26.5-27.9) to low-middle (27.9; 95% CI, 27.4-28.5), high-middle (29.2; 95% CI, 28.6-29.7), and high (31.8; 95% CI, 31.2-32.3) categories (P < .001). A significant, clinically unimportant longer length of stay was found for high inequality (2.5 days; 95% CI, 2.4-2.5 days) compared with low inequality (2.4 days; 95% CI, 2.4-2.5 days; P < .001) zip codes and between charges ($765 difference among groups; P < .001). Conclusions and Relevance: Children living in areas of high income inequality have higher rates of hospitalizations for ACSCs. Consideration of income inequality, in addition to income level, may provide a better understanding of the complex relationship between socioeconomic status and pediatric health outcomes for ACSCs. Efforts aimed at reducing rates of hospitalizations for ACSCs should consider focusing on areas with high income inequality.