Effects of Sociodemographic and Child Opportunity Index on Pediatric Plastic and Oral and Maxillofacial Surgical Volume Trends in the COVID-19 Pandemic.

Background: The coronavirus disease 2019 (COVID-19) pandemic caused disruptions to pediatric surgical care. Although surgical capacity has returned to the prepandemic state, barriers to surgical access may still exist for children who are medically underserved. We assessed pediatric plastic and oral and maxillofacial surgical volumes by sociodemographic characteristics before and during the COVID-19 pandemic. Methods: A 72-month retrospective cohort analysis of 10,681 pediatric plastic and oral and maxillofacial procedures between 2016 and 2021 was conducted. Multivariable logistic regression and interrupted time series analyses were used to analyze surgical volume trends by sociodemographic groups and Child Opportunity Index (COI). Results: Compared with prepandemic, patients undergoing procedures were more likely to be older than 18 years (P < 0.001) and Hispanic/Latino (adjusted odds ratio 1.38; 95% confidence interval, 1.14-1.68; P < 0.01). Surgical volume trends among patients from the lowest COI levels were lower than where they were estimated to have been if the pandemic did not occur (P = 0.040). Patients who spoke a primary language other than English or Spanish (P = 0.02) and patients with the lowest COI levels (P = 0.04) continued to have unrecovered surgical volumes. Conclusions: There were differences in the sociodemographic case-mix of patients undergoing plastic and oral and maxillofacial surgical procedures before and during the pandemic, and surgical volumes did not recover at the same rate for all patients. Further research can determine why certain sociodemographic groups and patients with low COI levels had decreased surgical access compared with prepandemic trends, and develop interventions focused on equitable pediatric surgical access.

Sociodemographic factors and Child Opportunity Index disparities associated with missed care opportunities in pediatric patients with lymphoma and leukemia referred for FDG-PET/CT.

BACKGROUND: Little data exists on the association of missed care opportunities (MCOs) in children referred for nuclear medicine/nuclear oncology imaging examinations and socioeconomic disparities. OBJECTIVE: To determine the prevalence of MCOs in children with lymphoma/leukemia scheduled for fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT) and the impact of sociodemographic factors and Child Opportunity Index (COI). MATERIALS AND METHODS: Retrospective analysis of MCOs in children with lymphoma/leukemia scheduled for FDG-PET/CT (2012 to 2022) was performed. In univariate analysis, patient, neighborhood, and appointment data were assessed across MCOs and completed appointments. Logistic regression evaluated independent effects of patient-, neighborhood-, and appointment-level factors with MCOs. Two-sided P-value < .05 was considered statistically significant. RESULTS: In 643 FDG-PET/CT appointments (n = 293 patients; median age 15 years (IQR 11.0-17.0 years); 37.9% female), there were 20 MCOs (3.1%) involving 16 patients. Only 8.2% appointments involved Black/African American non-Hispanic/Latino patients, yet they made up a quarter of total MCOs. Patients living in neighborhoods with very low or low COI experienced significantly higher MCOs versus zip codes with very high COI (6.9% vs. 0.8%; P = 0.02). Logistic regression revealed significantly increased likelihood of MCOs for patients aged 18 to 21 [odds ratio (OR) 4.50; 95% CI 1.53-13.27; P = 0.007], Black/African American non-Hispanic/Latino (OR 3.20; 95% CI 1.08-9.49; P = 0.04), zip codes with very low or low COI (OR 9.60; 95% CI 1.24-74.30; P = 0.03), and unknown insurance status. CONCLUSION: Children with lymphoma/leukemia, living in zip codes with very low or low COI, and who identified as Black/African American non-Hispanic/Latino experienced more MCOs. Our study supports the need to address intersecting sociodemographic, neighborhood, and health system factors that will improve equitable access to necessary healthcare imaging for children.

Pneumonia after hip surgery in children with neurological complex chronic conditions.

AIM: In children with neurological complex chronic conditions (CCC) undergoing hip surgery we aimed to: estimate the rate of postoperative pneumonia, determine the effect of pneumonia on postoperative hospital resource use, and identify predictors of postoperative pneumonia. METHOD: A retrospective cohort study was conducted utilizing the Pediatric Health Information System database for 2609 children (1081 females, 1528 males) aged 4 years and older with a neurological CCC who underwent hip surgery (i.e. reconstruction surgery or salvage procedure) between 2016 and 2018 in 41 US children's hospitals. Multivariable, mixed-effects logistic regression was used to assess patient characteristics and risk of pneumonia. RESULTS: Mean age at hip surgery was 10 years 1 month (SD 4y 8mo). The postoperative pneumonia rate was 1.6% (n=42). Median length of stay (LOS) was longer for children with pneumonia and the 30-day all-cause unplanned readmission rate and costs were higher. Variability in rates of pneumonia ranged from 1.1% to 2.8% across hospitals. Significant predictors of postoperative pneumonia were osteotomy type (p=0.005) and number of chronic conditions (p≤0.001). INTERPRETATION: Postoperative pneumonia after hip surgery in children with a neurological CCC is associated with longer LOS, readmissions, and higher costs. Children undergoing pelvic osteotomies and who have multimorbidity need additional clinical support to prevent postoperative pneumonia and decrease resource utilization. WHAT THIS PAPER ADDS: Pneumonia is a major postoperative complication in children with neurological complex chronic conditions (CCC). Forty-two (1.6%) children with neurological CCC developed pneumonia after hip surgery. Length of stay, readmissions, and costs were significantly higher in the group with pneumonia. Variability in pneumonia rates existed across hospitals. Predictors of developing pneumonia include osteotomy type and number of CCC.

Family Safety Reporting in Hospitalized Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Hospitalized children with medical complexity (CMC) are at high risk of medical errors. Their families are an underutilized source of hospital safety data. We evaluated safety concerns from families of hospitalized CMC and patient/parent characteristics associated with family safety concerns. METHODS: We conducted a 12-month prospective cohort study of English- and Spanish-speaking parents/staff of hospitalized CMC on 5 units caring for complex care patients at a tertiary care children's hospital. Parents completed safety and experience surveys predischarge. Staff completed surveys during meetings and shifts. Mixed-effects logistic regression with random intercepts controlling for clustering and other patient/parent factors evaluated associations between family safety concerns and patient/parent characteristics. RESULTS: A total of 155 parents and 214 staff completed surveys (>89% response rates). 43% (n = 66) had ≥1 hospital safety concerns, totaling 115 concerns (1-6 concerns each). On physician review, 69% of concerns were medical errors and 22% nonsafety-related quality issues. Most parents (68%) reported concerns to staff, particularly bedside nurses. Only 32% of parents recalled being told how to report safety concerns. Higher education (adjusted odds ratio 2.94, 95% confidence interval [1.21-7.14], P = .02) and longer length of stay (3.08 [1.29-7.38], P = .01) were associated with family safety concerns. CONCLUSIONS: Although parents of CMC were infrequently advised about how to report safety concerns, they frequently identified medical errors during hospitalization. Hospitals should provide clear mechanisms for families, particularly of CMC and those from disadvantaged backgrounds, to share safety concerns. Actively engaging patients/families in reporting will allow hospitals to develop a more comprehensive, patient-centered view of safety.

Ceftriaxone with Metronidazole versus Piperacillin/Tazobactam in the management of complicated appendicitis in children: Results from a multicenter pediatric NSQIP analysis.

BACKGROUND: Narrow-spectrum antibiotics have been found to be equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in children with uncomplicated appendicitis. Comparative effectiveness data for children with complicated appendicitis remains limited. This investigation aimed to compare outcomes between the most common narrow-spectrum regimen (ceftriaxone with metronidazole: CM) and anti-Pseudomonal regimen (piperacillin/tazobactam: PT) used perioperatively in children with complicated appendicitis. METHODS: Multicenter retrospective cohort study using clinical data from the NSQIP-Pediatric Appendectomy Collaborative database merged with antibiotic utilization data from the Pediatric Health Information System database. Mixed-effects multivariate regression was used to compare NSQIP-defined outcomes and resource utilization between treatment groups after adjusting for patient characteristics, disease severity, and clustering of outcomes within hospitals. RESULTS: 654 patients from 14 hospitals were included, of which 37.9% received CM and 62.1% received PT. Following adjustment, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]). CONCLUSIONS: Rates of organ space infection and resource utilization were similar in children with complicated appendicitis treated with ceftriaxone plus metronidazole and piperacillin/tazobactam. LEVEL OF EVIDENCE: Level III: Treatment study - Retrospective comparative study.

Implementing receiver-driven handoffs to the emergency department to reduce miscommunication.

BACKGROUND: Miscommunications during care transfers are a leading cause of medical errors. Recent consensus-based recommendations to standardise information transfer from outpatient clinics to the emergency department (ED) have not been formally evaluated. We sought to determine whether a receiver-driven structured handoff intervention is associated with 1) increased inclusion of standardised elements; 2) reduced miscommunications and 3) increased perceived quality, safety and efficiency. METHODS: We conducted a prospective intervention study in a paediatric ED and affiliated clinics in 2016-2018. We developed a bundled handoff intervention included a standard template, receiver training, awareness campaign and iterative feedback. We assessed a random sample of audio-recorded handoffs and associated medical records to measure rates of inclusion of standardised elements and rate of miscommunications. We surveyed key stakeholders pre-intervention and post-intervention to assess perceptions of quality, safety and efficiency of the handoff process. RESULTS: Across 162 handoffs, implementation of a receiver-driven intervention was associated with significantly increased inclusion of important elements, including illness severity (46% vs 77%), tasks completed (64% vs 83%), expectations (61% vs 76%), pending tests (0% vs 64%), contingency plans (0% vs 54%), detailed callback request (7% vs 81%) and synthesis (2% vs 73%). Miscommunications decreased from 48% to 26%, a relative reduction of 23% (95% CI -39% to -7%). Perceptions of quality (35% vs 59%), safety (43% vs 73%) and efficiency (17% vs 72%) improved significantly post-intervention. CONCLUSIONS: Implementation of a receiver-driven intervention to standardise clinic-to-ED handoffs was associated with improved communication quality. These findings suggest that expanded implementation of similar programmes may significantly improve the care of patients transferred to the paediatric ED.

Ceftriaxone Combined With Metronidazole is Superior to Cefoxitin Alone in the Management of Uncomplicated Appendicitis in Children: Results from a Multicenter Collaborative Comparative Effectiveness Study.

OBJECTIVE: To compare rates of surgical site infection between the 2 most commonly utilized narrow-spectrum antibiotic regimens in children with uncomplicated appendicitis (ceftriaxone with metronidazole and cefoxitin alone). SUMMARY OF BACKGROUND DATA: Narrow-spectrum antibiotics have been found to be equivalent to extended-spectrum (antipseudomonal) agents in preventing surgical site infection (SSI) in children with uncomplicated appendicitis. The comparative effectiveness of different narrow-spectrum agents has not been reported. METHODS: This was a multicenter retrospective cohort study using clinical data from the Pediatric National Surgical Quality Improvement Program Appendectomy Collaborative Pilot database merged with antibiotic utilization data from the Pediatric Health Information System database from January 2013 to June 2015. Multivariable logistic regression was used to compare outcomes between antibiotic treatment groups after adjusting for patient characteristics, surrogate measures of disease severity, and clustering of outcomes within hospitals. RESULTS: Eight hundred forty-six patients from 14 hospitals were included in the final study cohort with an overall SSI rate of 1.3%. A total of 56.0% of patients received ceftriaxone with metronidazole (hospital range: 0%-100%) and 44.0% received cefoxitin (range: 0%-100%). In the multivariable model, ceftriaxone with metronidazole was associated with a 90% reduction in the odds of a SSI compared to cefoxitin [0.2% vs 2.7%; odds ratio: 0.10 (95% confidence interval 0.02-0.60); P = 0.01]. CONCLUSIONS: Ceftriaxone combined with metronidazole is superior to cefoxitin alone in preventing SSIs in children with uncomplicated appendicitis.

Hospital resource use after hip reconstruction surgery in children with neurological complex chronic conditions.

AIM: To assess how co-occurring conditions influence recovery after hip reconstruction surgery in children with neurological complex chronic conditions (CCCs). METHOD: This was a retrospective analysis of 4058 children age 4 years or older with neurological CCCs who underwent hip reconstructive surgery between 1st January 2015 and 31st December 2018 in 49 children's hospitals. The presence of co-occurring chronic conditions was assessed using the Agency for Healthcare Research Chronic Condition Indicator system. Multivariable, hierarchical regression was used to assess the relationship between co-existing conditions and postoperative hospital length of stay (LOS), cost, and 30-day readmission rate. RESULTS: The most common co-occurring conditions were digestive (60.1%) and respiratory (37.9%). As the number of co-existing conditions increased from one to four or more, median LOS increased 67% (3d [interquartile range {IQR} 2-4d] to 5d [IQR 3-8d]); median hospital cost increased 41% ($20 248 [IQR $14 921-$27 842] to $28 692 [IQR $19 236-$45 887]); and readmission rates increased 250% (5.5-13.9%), p<0.001 for all. Of all specific co-existing chronic conditions, malnutrition was associated with the greatest increase in postoperative hospital resource use. INTERPRETATION: Co-occurring conditions, and malnutrition in particular, are a significant risk factor for prolonged, in-hospital recovery after hip reconstruction surgery in children with a neurological CCC. Further investigation is necessary to assess how improved preoperative optimization of multiple co-occurring conditions may improve postoperative outcomes and resource utilization. WHAT THIS PAPER ADDS: Children with neurological complex chronic conditions (CCCs) often develop hip disorders which require hip reconstruction surgery. Co-occurring conditions are common in children with neuromuscular CCCs. Having four or more chronic conditions was associated with a longer length of stay, increased costs, and higher odds of readmission. Malnutrition was a significant risk factor for prolonged hospitalization after hip reconstruction surgery.

Development and Implications of an Evidence-based and Public Health-relevant Definition of Complicated Appendicitis in Children.

OBJECTIVE: To characterize the influence of intraoperative findings on complications and resource utilization as a means to establish an evidence-based and public health-relevant definition for complicated appendicitis. SUMMARY OF BACKGROUND DATA: Consensus is lacking surrounding the definition of complicated appendicitis in children. Establishment of a consensus definition may have implications for standardizing the reporting of clinical research data and for refining reimbursement guidelines. METHODS: This was a retrospective cohort study of patients ages 3 to 18 years who underwent appendectomy from January 1, 2013 to December 31, 2014 across 22 children's hospitals (n = 5002). Intraoperative findings and clinical data from the National Surgical Quality Improvement Program-Pediatric Appendectomy Pilot Database were merged with cost data from the Pediatric Health Information System Database. Multivariable regression was used to examine the influence of 4 intraoperative findings [visible hole (VH), diffuse fibrinopurulent exudate (DFE) extending outside the right lower quadrant (RLQ)/pelvis, abscess, and extra-luminal fecalith] on complication rates and resource utilization after controlling for patient and hospital-level characteristics. RESULTS: At least 1 of the 4 intraoperative findings was reported in 26.6% (1333/5002) of all cases. Following adjustment, each of the 4 findings was independently associated with higher rates of adverse events compared with cases where the findings were absent (VH: OR 5.57 [95% CI 3.48-8.93], DFE: OR 4.65[95% CI 2.91-7.42], abscess: OR 8.96[95% CI 5.33-15.08], P < 0.0001, fecalith: OR 5.01[95% CI 2.02-12.43], P = 0.001), and higher rates of revisits (VH: OR 2.02 [95% CI 1.34-3.04], P = 0.001, DFE: OR 1.59[95% CI 1.07-2.37], P = 0.02, abscess: OR 2.04[95% CI 1.2-3.49], P = 0.01, fecalith: OR 2.31[95% CI 1.06-5.02], P = 0.04). Each of the 4 findings was also independently associated with increased resource utilization, including longer cumulative length of stay (VH: Rate ratio [RR] 3.15[95% CI 2.86-3.46], DFE: RR 3.06 [95% CI 2.83-3.13], abscess: RR 3.94 [95% CI 3.55-4.37], fecalith: RR 2.35 [95% CI 1.87-2.96], P =  < 0.0001) and higher cumulative hospital cost (VH: RR 1.97[95% CI 1.64-2.37], P < 0.0001, DFE: RR 1.8[95% CI 1.55-2.08], P =  < 0.0001, abscess: RR 2.02[95% CI 1.61-2.53], P < 0.0001, fecalith: RR 1.49[95% CI 0.98-2.28], P = 0.06) compared with cases where the findings were absent. CONCLUSION AND RELEVANCE: The presence of a visible hole, diffuse fibrinopurulent exudate, intra-abdominal abscess, and extraluminal fecalith were independently associated with markedly worse outcomes and higher cost in children with appendicitis. The results of this study provide an evidence-based and public health-relevant framework for defining complicated appendicitis in children.

Variation in surgical management of asymptomatic umbilical hernia at freestanding children's hospitals.

PURPOSE: To examine hospital-level variation in the timing of asymptomatic umbilical hernia repair in children. METHODS: Retrospective analysis of children undergoing umbilical hernia repair at 38 children's hospitals using the Pediatric Health Information System database (01/2013-12/2017). Early repair was defined as surgery performed at 3 years of age or younger. Repairs were categorized as emergent/urgent if associated with diagnostic or procedural codes indicating obstruction or strangulation, or if they occurred within 2 weeks of an emergency department encounter. Multivariable regression was used to calculate hospital-level observed-to-expected (O/E) ratios for early repair adjusting for emergent/urgent repair and patient characteristics. RESULTS: 23,144 children were included, of which 30% underwent early repair (hospital range: 6.9%-54.3%, p ≪ 0.001). Overall, 3.8% of all repairs were emergent/urgent, and higher rates of early repair did not correlate with higher rates of emergent/urgent repair across hospitals (r = -0.10). Following adjustment, hospital-level O/E ratios for early repair varied 8.9-fold (0.19-1.70, p ≪ 0.001). CONCLUSION: Timing of asymptomatic umbilical hernia repair varies widely across children's hospitals, and the magnitude of this variation cannot be explained by differences in patient characteristics or the acuity of repair. Many children may be undergoing repair of hernias that may spontaneously close with further observation. LEVEL OF EVIDENCE: Level III (retrospective comparative study).

Pit-picking resolves pilonidal disease in adolescents.

PURPOSE: The purpose of the study was to evaluate the outcome of pit-picking on adolescents with pilonidal disease. METHODS: Patients presenting to a Pilonidal Clinic were managed by evacuation of any un-drained collections, soaking, and as needed, hair removal. Once active inflammation resolved, they underwent pit-picking under local anesthesia. Those with >3 pits underwent sequential pit-pickings 2 months apart. Hirsute patients also underwent laser hair epilation. Pilonidal disease was stratified by severity. Patient symptoms were collected prospectively and reviewed. RESULTS: Fifty-eight patients underwent at least one pit-picking from February 2016 to September 2017. There were 40 (69%) males with a mean age of 17.7 years (range 13-24). Thirty-seven hirsute patients (64%) underwent a series of laser epilation treatments. Patients required from 0 to 3 days of non-narcotic analgesia, and all returned promptly to pre-procedure activities. Seven patients (12%) were lost to follow-up. Of the 51 patients with follow-up data, 47 (92%) were symptom-free an average of 5.0 months (range 1-20) post-procedure. Four patients (8%) had persistent intermittent drainage. CONCLUSION: Pit-picking is a simple office procedure that may resolve pilonidal disease in many adolescents. A longer follow-up interval is needed to determine the long-term recurrence rate. TYPE OF STUDY: Case Series. LEVEL OF EVIDENCE: Level IV.

Association of Intraoperative Findings With Outcomes and Resource Use in Children With Complicated Appendicitis.

Importance: The influence of disease severity on outcomes and use of health care resources in children with complicated appendicitis is poorly characterized. Adjustment for variation in disease severity may have implications for ensuring fair reimbursement and comparative performance reporting among hospitals. Objective: To examine the association of intraoperative findings as a measure of disease severity with complication rates and resource use in children with complicated appendicitis. Design: This retrospective cohort study used clinical data from the American College of Surgeons National Surgical Quality Improvement Program pediatric appendectomy pilot database (NSQIP-P database) and cost data from the Pediatric Health Information System database. Twenty-two children's hospitals participated in the NSQIP Pediatric Appendectomy Collaborative Pilot Project. Patients aged 3 to 18 years with complicated appendicitis who underwent an appendectomy from January 1, 2013, through December 31, 2014, were included in the study. Appendicitis was categorized in the NSQIP-P database as complicated if any of the following 4 intraoperative findings occurred in the operative report: visible hole, fibropurulent exudate in more than 2 quadrants, abscess, or extraluminal fecalith. Data were analyzed from January 1, 2013, through December 31, 2014. Main Outcomes and Measures: Thirty-day postoperative adverse event rate, revisit rate, hospital cost, and length of stay. Multivariable regression was used to estimate event rates and outcomes for all observed combinations of intraoperative findings, with adjusting for patient characteristics and clustering within hospitals. Results: A total of 1333 patients (58.7% boys; median age, 10 years; interquartile range, 7-12 years) were included; multiple intraoperative findings of complicated appendicitis were reported in 589 (44.2%). Compared with single findings, the presence of multiple findings was associated with higher rates of surgical site infection (odds ratio, 1.40; 95% CI, 0.95-2.06; P = .09), higher revisit rates (odds ratio, 1.60; 95% CI, 1.15-2.21; P = .005), longer length of stay (rate ratio, 1.45; 95% CI, 1.36-1.55; P < .001), and higher hospital cost (rate ratio, 1.35; 95% CI, 1.19-1.53; P < .001). Significant differences were found among different combinations of intraoperative findings for all outcomes, including a 3.6-fold difference in rates of surgical site infection (range, 7.5% for fecalith alone to 27.2% for all 4 findings; P = .002), a 2.6-fold difference in revisit rates (range, 8.9% for exudate alone to 22.9% for all 4 findings; P = .001), a 2.2-fold difference in length of stay (range, 4.0 days for exudate alone to 8.9 days for all 4 findings; P < .001), and a 2.4-fold difference in mean cumulative cost (range, $13 296 for exudate alone to $32 282 for all 4 findings; P < .001). Conclusions and Relevance: More severe presentations of complicated appendicitis are associated with worse outcomes and greater resource use. Severity adjustment may be needed to ensure fair reimbursement and comparative performance reporting, particularly at hospitals treating underserved populations where more severe presentations are common.

Reducing Readmissions Post-tonsillectomy: A Quality Improvement Study on Intravenous Hydration.

INTRODUCTION: Dehydration is a potentially preventable complication post-tonsillectomy and can result in an Emergency Department visit and/or readmission. Our objectives were to identify risk factors for dehydration readmissions and develop interventions to prevent them. METHODS: We used retrospective chart reviews to determine if increased intravenous (IV) hydration post-tonsillectomy prevented hospital readmissions for dehydration. All children aged 1-18 years who underwent tonsillectomy between July 1, 2007 and September 30, 2015 were included in this quality improvement study. Using the Pediatric Health Information System database, patients who experienced a readmission for dehydration within 72 hours of surgery were identified and validated with internal data. We analyzed the pre-implementation and post-implementation readmission rates after standardization of increased IV fluids (1.5 times maintenance). An interrupted time series analysis was used to estimate the effects of our hydration initiative. RESULTS: Of 11,157 patients who underwent tonsillectomy during the study period, 96 (0.9%) met the criteria for readmissions for dehydration. The pre-implementation readmission rate was 1% compared to 0.2% post-implementation, a reduction of 82%. CONCLUSIONS: The hydration initiative was associated with a significant decrease in hospital readmissions. This safe, low-cost, easy-to-implement approach to preventing dehydration post-tonsillectomy could be explored at other institutions.

Extended Versus Narrow-spectrum Antibiotics in the Management of Uncomplicated Appendicitis in Children: A Propensity-matched Comparative Effectiveness Study.

OBJECTIVE: The aim of this study was to compare the effectiveness of extended versus narrow spectrum antibiotics in preventing surgical site infections (SSIs) and hospital revisits in children with uncomplicated appendicitis. SUMMARY OF BACKGROUND DATA: There is a paucity of high-quality evidence in the pediatric literature comparing the effectiveness of extended versus narrow-spectrum antibiotics in the prevention of SSIs associated with uncomplicated appendicitis. METHODS: Clinical data from the ACS NSQIP-Pediatric Appendectomy Pilot Project were merged with antibiotic utilization data from the Pediatric Health Information System database for patients undergoing appendectomy for uncomplicated appendicitis at 17 hospitals from January 1, 2013 to June 30, 2015. Patients who received piperacillin/tazobactam (extended spectrum) were compared with those who received either cefoxitin or ceftriaxone with metronidazole (narrow spectrum) after propensity matching on demographic and severity characteristics. Study outcomes were 30-day SSI and hospital revisit rates. RESULTS: Of the 1389 patients included, 39.1% received piperacillin/tazobactam (range by hospital: 0% to 100%), and the remainder received narrow-spectrum agents. No differences in demographics or severity characteristics were found between groups following matching. In the matched analysis, the rates of SSI were similar between groups [extended spectrum: 2.4% vs narrow spectrum 1.8% (odds ratio, OR: 1.05, 95% confidence interval, 95% CI 0.34-3.26)], as was the rate of revisits [extended spectrum: 7.9% vs narrow spectrum 5.1% (OR: 1.46, 95% CI 0.75-2.87)]. CONCLUSIONS: Use of extended-spectrum antibiotics was not associated with lower rates of SSI or hospital revisits when compared with narrow-spectrum antibiotics in children with uncomplicated appendicitis. Our results challenge the routine use of extended-spectrum antibiotics observed at many hospitals, particularly given the increasing incidence of antibiotic-resistant organisms.

Parent-Provider Miscommunications in Hospitalized Children.

BACKGROUND: Miscommunications lead to medical errors and suboptimal hospital experience. Parent-provider miscommunications are understudied. OBJECTIVES: (1) Examine characteristics of parent-provider miscommunications about hospitalized children, (2) describe associations among parent-provider miscommunications, parent-reported errors, and hospital experience, and (3) compare parent and attending physician reports of parent-provider miscommunications. METHODS: Prospective cohort study of 471 parents of 0- to 17-year-old medical inpatients in a pediatric hospital between May 1, 2013 and October 1, 2014. At discharge, parents reported parent-provider miscommunication and type (selecting all applicable responses), overall experience, and errors during hospitalization. During discharge billing, the attending physicians (n = 52) of a subset of patients (n = 217) also reported miscommunications, enabling comparison of parent and attending physician reports. We used logistic regression to examine characteristics of parent-reported miscommunications; McNemar's test to examine associations between miscommunications, errors, and top-box (eg, "excellent") experience; and generalized estimating equations to compare parent- and attending physician-reported miscommunication rates. RESULTS: Parents completed 406 surveys (86.2% response rate). 15.3% of parents (n = 62) reported miscommunications. Parents of patients with nonpublic insurance (odds ratio: 1.99; 95% confidence interval: 1.03-3.85) and longer lengths of stay (odds ratio: 1.12; 95% confidence interval: 1.02-1.23) more commonly reported miscommunications. Parents reporting miscommunications were 5.3 times more likely to report errors and 78.6% less likely to report top-box overall experience (P < .001 for both). Among patients with both parent and attending physician surveys, 16.1% (n = 35) of parents and 3.7% (n = 8) of attending physicians reported miscommunications (P < .001). Both parents and attending physicians attributed miscommunications most often to family receipt of conflicting information. CONCLUSIONS: Parent-provider miscommunications were associated with parent-reported errors and suboptimal hospital experience. Parents reported parent-provider miscommunications more often than attending physicians did.

Patient Characteristics and Surgical Approach Impacting Simultaneous to Alternate Prism Cover Test Disparity After Exotropia Surgery: A Quantitative Look at the Difference in Motor Outcomes.

PURPOSE: To investigate the relationship between simultaneous prism and cover test (SPCT) and alternate prism and cover test (APCT) outcomes after exotropia surgery, and to identify characteristics associated with significant disparity between them. METHODS: Review of sensorimotor outcomes 2 to 6 months after exotropia surgery identified patients with alignment documented by both SPCT and APCT at the same examination. Two hundred seventy-four and 319 patients had both measurements recorded at distance and near, respectively. Correlation between the SPCT and APCT and range of APCT when the SPCT measurement was zero were determined. Patient characteristics studied for association with a difference between the SPCT and APCT exceeding known APCT test-retest variability included age, visual acuity, fusion, intermittency, pattern, preoperative and postoperative angle, and treatment with or without medial rectus resection. RESULTS: SPCT and APCT outcomes were strongly correlated (P < .001), significantly different (P < .001), and linearly related. The percentage of patients who were orthotropic (SPCT = 0) was 76% at distance and 80% at near. Misalignment of 10 prism diopters (PD) or less by the APCT was present in 92% of orthotropic patients at distance and 84% at near. Surgery without medial rectus resection (P = .015), larger preoperative angle (P = .003), intermittent exotropia (P = .028), and postoperative exotropia rather than esotropia (P < .001) were associated with a significant SPCT-APCT difference. CONCLUSIONS: Although a greater postoperative SPCT-APCT disparity was confirmed for patients with intermittent exotropia, it also independently associated with a larger preoperative deviation and surgery without medial rectus resection. Performing medial rectus resection, a surgeon's prerogative, provides more apparently consistent postoperative alignment characterized by less SPCT-APCT disparity. [J Pediatr Ophthalmol Strabismus. 2017;54(4):222-230.].

Trends in Hospital Utilization and Costs among Pediatric Palliative Care Recipients.

OBJECTIVE AND BACKGROUND: Few previous studies have explored how pediatric palliative care (PPC) influences hospital utilization. We evaluated this among PPC recipients in a single center. METHODS: This is a retrospective cohort study of 109 patients ≥2 years of age who received PPC consultation at a large quaternary children's hospital from April 2009 to September 2010. We assessed frequencies of hospital admissions and emergency department (ED) visits, use of intensive interventions, and hospital costs. Generalized estimating equations were used to compare outcomes in the two years before and after PPC consultation, stratifying by whether a patient survived two or more years following PPC enrollment. RESULTS: Median age at PPC consultation was 13 years (interquartile range 6-18); 56.0% were male (n = 61), 69.7% white non-Hispanic (n = 76). Fifty-nine percent (n = 64) of patients died during the study period. Overall, annual hospital admission rates decreased from 4.6 (95% confidence interval [CI] 4.0-5.4) before PPC consultation to 3.7 (95% CI 3.4-4.4) after (p = 0.025). Annual ED visits decreased from 0.9 (95% CI 0.7-1.2) to 0.6 (95% CI 0.4-0.8) (p = 0.030). Survivors had significantly decreased hospital admissions [rate ratio (RR) 0.57 (95% CI 0.45-0.73), p < 0.001] and ED visits [RR 0.33 (95% CI 0.20-0.54), p < 0.001]. Decedents had increased intensive care unit use (p = 0.029) but decreased operations (p = 0.002); survivors experienced no change in these outcomes after PPC consultation. Hospital costs remained stable for all (p = 0.929). DISCUSSION: PPC involvement may contribute to decreased hospital and ED use, without escalating costs. These outcomes are most evident in survivors. Hence, PPC may have a measurable long-term impact on hospital use in seriously ill children.

Transition and transfer of childhood cancer survivors to adult care: A national survey of pediatric oncologists.

BACKGROUND: Pediatric oncologists are responsible for ensuring that adolescent and young adult (AYA) childhood cancer survivors have the knowledge and skills necessary to manage their follow-up care in adult healthcare systems. PROCEDURES: To describe transition practices and barriers to transfer, we electronically surveyed U.S. Children's Oncology Group members: 507/1449 responded (35%) and 347/507 (68%) met eligibility criteria. RESULTS: Of 347 respondents, 50% are male, median years in practice 10 (range 5-22), 37% practice in freestanding children's hospitals. Almost all care for survivors up to age 21 years (96%), 42% care for survivors over age 25 years, and only 16% over age 30 years. While 66% of oncologists reported providing transition education to their patients, very few (8%) reported using standardized transition assessments. The most frequent barriers to transfer were perceived attachment to provider (91%), lack of adult providers with cancer survivor expertise (86%), patient's cognitive delay (81%), or unstable social situation (80%). Oncologists who continue to care for patients older than 25 years are more likely to perceive parents' attachment to provider (P = 0.037) and patients' social situation as barriers to transfer (P = 0.044).  Four themes emerged from a content analysis of 75 respondents to the open-ended question inviting comments on transition/transfer practices: desire for flexible transfer criteria; providers as barriers; provider lack of transition knowledge, skills, and resources; and desire for collaboration. CONCLUSIONS: Although most pediatric oncologists reported transferring AYA cancer survivors to adult care and providing some transition education, they endorse deficits in transition skills, emotional readiness, and institutional resources.

National Variability and Appropriateness of Surgical Antibiotic Prophylaxis in US Children's Hospitals.

IMPORTANCE: Appropriate use of surgical antibiotic prophylaxis (AP) reduces surgical site infection rates, but prior data suggest variability in use patterns. OBJECTIVE: To assess national variability and appropriateness of AP in pediatric surgical patients. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 31 freestanding children's hospitals in the United States using administrative data from 2010-2013. The study included 603 734 children younger than 18 years who underwent one of the 45 most commonly performed operations. EXPOSURES: Receipt of surgical AP. MAIN OUTCOMES AND MEASURES: Primary outcomes included procedure- and hospital-specific rates of AP use and appropriateness of use based on clinical guidelines and consensus statements. We also assessed rates of Clostridium difficile infection and potential allergic reactions (using epinephrine administration as a surrogate event) after AP receipt. RESULTS: Of the 603 734 eligible patients, the mean (SD) patient age was 4.8 (4.4) years and 384 571 (63.7%) were boys. For the 671 255 operations evaluated, AP was administered for 348 119 (52%) of procedures. Intrahospital variation in AP use by procedure ranged from 11.5% to 100% (median, 78.1%). Overall, AP use was considered appropriate for 64.6% of cases. Appropriate use of AP by hospital varied from 47.3% to 84.4% with large variability by procedure within each hospital. For procedures for which AP was indicated, the median rate of appropriate use by hospital was 93.8%; however, for procedures for which AP was not indicated, the median rate of appropriate use by hospital was 52.0%. The odds of C difficile infection and epinephrine administration were significantly higher among children who received AP (odds ratio, 3.34; 95% CI, 1.66-6.73 and odds ratio 1.97; 95% CI, 1.92-2.02; respectively). CONCLUSIONS AND RELEVANCE: There is substantial national variability in the overall and appropriate use of AP for the most commonly performed operations in children both at a procedure and hospital level. A high proportion of AP use is inappropriate, potentially exposing many children to avoidable adverse events. Urgent attention should be directed to efforts to standardize the use of surgical AP in pediatrics.

Parent-Reported Errors and Adverse Events in Hospitalized Children.

IMPORTANCE: Limited data exist regarding the incidence and nature of patient- and family-reported medical errors, particularly in pediatrics. OBJECTIVE: To determine the frequency with which parents experience patient safety incidents and the proportion of reported incidents that meet standard definitions of medical errors and preventable adverse events (AEs). DESIGN, SETTING, AND PARTICIPANTS: We conducted a prospective cohort study from May 2013 to October 2014 within 2 general pediatric units at a children's hospital. Included in the study were English-speaking parents (N = 471) of randomly selected inpatients (ages 0-17 years) prior to discharge. Parents reported via written survey whether their child experienced any safety incidents during hospitalization. Two physician reviewers classified incidents as medical errors, other quality issues, or exclusions (κ = 0.64; agreement = 78%). They then categorized medical errors as harmful (ie, preventable AEs) or nonharmful (κ = 0.77; agreement = 89%). We analyzed errors/AEs using descriptive statistics and explored predictors of parent-reported errors using bivariate statistics. We subsequently reviewed patient medical records to determine the number of parent-reported errors that were present in the medical record. We obtained demographic/clinical data from hospital administrative records. MAIN OUTCOMES AND MEASURES: Medical errors and preventable AEs. RESULTS: The mean (SD) age of the 383 parents surveyed was 36.6 (8.9) years; most respondents (n = 266) were female. Of 383 parents surveyed (81% response rate), 34 parents (8.9%) reported 37 safety incidents. Among these, 62% (n = 23, 6.0 per 100 admissions) were determined to be medical errors on physician review, 24% (n = 9) were determined to be other quality problems, and 14% (n = 5) were determined to be neither. Thirty percent (n = 7, 1.8 per 100 admissions) of medical errors caused harm (ie, were preventable AEs). On bivariate analysis, children with medical errors appeared to have longer lengths of stay (median [interquartile range], 2.9 days [2.2-6.9] vs 2.5 days [1.9-4.1]; P = .04), more often had a metabolic (14.3% vs 3.0%; P = .04) or neuromuscular (14.3% vs 3.6%; P = .05) condition, and more often had an annual household income greater than $100,000 (38.1% vs 30.1%; P = .06) than those without errors. Fifty-seven percent (n = 13) of parent-reported medical errors were also identified on subsequent medical record review. CONCLUSIONS AND RELEVANCE: Parents frequently reported errors and preventable AEs, many of which were not otherwise documented in the medical record. Families are an underused source of data about errors, particularly preventable AEs. Hospitals may wish to consider incorporating family reports into routine safety surveillance systems.