Persistent Opioid Use Following Pediatric Nonfatal Firearm Injury.

OBJECTIVE: Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims. METHODS: We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use. RESULTS: Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use. CONCLUSIONS: Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.

Costs associated with acute kidney injury in critically Ill neonates with patent Ductus arteriosus: pediatric health information system (PHIS) analysis.

OBJECTIVE: Compare costs of hospitalization between critically-ill neonates with patent ductus arteriosus (PDA) who did and did not develop acute kidney injury (AKI). STUDY DESIGN: Using the Children's Hospital Association's Pediatric Health Information System (PHIS) database, we ascertained the marginal estimated total cost of hospitalization between those who did and did not develop AKI. RESULTS: Query of 49 PHIS centers yielded 14,217 neonates with PDA, 1697 with AKI and 12,520 without AKI. Predictors of cost included AKI, birth weight, ethnicity, race, length of stay (LOS), and Feudtner Complex Chronic Conditions Classification System. LOS was the strongest predictor (AKI: median 71 days [IQR 28-130]; No AKI: 28 days [10-76]; p < 0.01). Neonates with AKI had $48,416 greater costs (95% CI: $43,804-53,227) after adjusting for these predictors (AKI: $190,063, 95% CI $183,735-196,610; No AKI: $141,647, 95% CI $139,931-143,383 l; p < 0.01). CONCLUSION: AKI is independently associated with increased hospital costs in critically-ill neonates with PDA.

The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One.

Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN: Retrospective, quasi-experimental study. SETTING: We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. PARTICIPANTS: We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES: Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS: Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; p < 0.0001), length of stay (8 vs 22 d; p < 0.0001), and cumulative charges ($118,686 vs $308,977; p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; p < 0.0001]). CONCLUSIONS AND RELEVANCE: Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.

Missing data methods for intensive care unit SOFA scores in electronic health records studies: results from a Monte Carlo simulation.

Aim: Missing data cause problems through decreasing sample size and the potential for introducing bias. We tested four missing data methods on the Sequential Organ Failure Assessment (SOFA) score, an intensive care research severity adjuster. Methods: Simulation study using 2015-2017 electronic health record data, where the complete dataset was sampled, missing SOFA score elements imposed and performance examined of four missing data methods - complete case analysis, median imputation, zero imputation (recommended by SOFA score creators) and multiple imputation (MI) - on the outcome of in-hospital mortality. Results: MI performed well, whereas other methods introduced varying amounts of bias or decreased sample size. Conclusion: We recommend using MI in analyses where SOFA score component values are missing in administrative data research.

A comparison of administrative claims-based risk predictors for pediatric asthma.

OBJECTIVES: Head-to-head comparisons are needed to determine the most accurate and appropriate administrative claims-based exacerbation risk predictor for emergency department (ED) visits and hospitalizations among children with asthma. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed 2013-2014 MarketScan Medicaid data. Children aged 2 to 17 years were included. Seven risk predictors were compared for accuracy in predicting 3-month subsequent ED visits/hospitalizations for asthma: 3-month rolling asthma medication ratio (AMR), Healthcare Effectiveness Data and Information Set (HEDIS) criteria, revised HEDIS criteria, quarterly short-acting ß-agonist (SABA) claims, prior ED visit, prior hospitalization, and prior ED visit or hospitalization. Sensitivity, specificity, positive and negative predictive value (NPV), and percentage of population identified as high risk were compared for each risk predictor utilizing the McNemar test to identify statistically significant differences in risk prediction accuracy. RESULTS: A total of 214,452 children were included; the mean age was 7.8 years. HEDIS and revised HEDIS identified prohibitively large cohorts as high risk (67% and 48%, respectively). For the remaining measures, the NPV range is narrow (97%-99%), indicating high performance at identifying patients who would not benefit from intervention. The ED visit and ED/hospitalization measures have superior sensitivities (44% and 49%, respectively) compared with pharmacy claims-based measures (AMR [5%] and SABA count [10%]). Pharmacy claims-based measures identify a smaller proportion of patients as high risk and maintain high NPV. CONCLUSIONS: Pharmacy-based asthma exacerbation risk predictors such as the AMR and SABA count can rule out low-risk patients with a high degree of specificity and NPV, which is a primary goal of real-time risk monitoring in pediatric asthma.

Nurse Perspectives Regarding Implementation of an Asthma Monitoring Mobile Health Application in the School Setting.

Background: School-based telehealth (SBTH) plays a valuable role in child asthma management, although nurses have concerns with caregiver engagement. Mobile technology (m-health) has potential to improve this engagement. Objective: We identified barriers and key desired features of an asthma m-health application as a supplement to an existing SBTH asthma program in rural settings. Methods: Multimethod design using school nurse surveys and interviews with school and SBTH personnel to describe processes related to implementation of an m-health application. Results: Nurses reported SBTH programs were an ideal setting to identify potential families for m-health. Benefits of caregiver education and engagement and barriers related to technology, smart phone data availability, and family buy-in were described. Desired application features included education on inhaler technique, asthma symptom, and medication adherence reports. Conclusions: The feedback identified from nurses can be incorporated into an asthma m-health program within an SBTH program to facilitate implementation.

Assessing Health Care Utilization and Compliance in Kawasaki Disease.

OBJECTIVE: To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN: We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS: The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS: Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.

A Cost Comparison of Infliximab Versus Intravenous Immunoglobulin for Refractory Kawasaki Disease Treatment.

BACKGROUND AND OBJECTIVES: In 10% to 20% of cases, Kawasaki disease is refractory to intravenous immunoglobulin (IVIg), an expensive medication under a national shortage. Data suggest that infliximab is a viable alternative to a second dose of IVIg, with similar efficacy and safety. We compared the cost of a second IVIg dose to that of infliximab in the treatment of refractory Kawasaki disease (rKD). METHODS: A decision analysis model was used to compare rKD treatments: a second dose of IVIg at 2 g/kg versus infliximab at 10 mg/kg. Infliximab monitoring times were 24, 36, and 48 hours. Direct hospital costs beginning at rKD diagnosis were estimated by using 2016-2017 Truven MarketScan data. Redbook was used for drug costs. Calculations were applied to 3 hypothetical cohorts of 100 patients aged 2 (12.5 kg), 4 (16 kg), and 8 years (25.5 kg). Indirect costs included parental missed workdays. RESULTS: The total direct cost for children receiving IVIg was $1 677 801, $1 791 652, and $2 100 675 for the 2-, 4-, and 8-year-old cohorts. The direct cost of infliximab with 24 hours of monitoring was $853 042, $899 096, and $1 024 101, respectively. A 20% bidirectional sensitivity analysis revealed stability of our model, with overall cost savings with use of infliximab. With monitoring 48 hours after infliximab treatment, 20% changes in length of stay (LOS) tipped the balance for the 2- and 4-year-old cohorts. Overall, IVIg and infliximab LOS had the most influence on our model. CONCLUSIONS: Infliximab has potential to yield shorter LOS and significant cost savings in the treatment of rKD. Infliximab treatment, followed by 24 hours of monitoring, nearly halved hospital costs, regardless of age.

A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid.

Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.

Loop diuretic use among patients with heart failure and type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors.

AIMS: To compare loop diuretic use in patients with comorbid heart failure (HF) and type 2 diabetes (T2D) newly initiated on sodium glucose cotransporter-2 inhibitors (SGLT2Is) versus other oral anti-glycemic agents (AGAs). METHODS: This analysis used 2013-2015 MarketScan Medicare Supplemental claims data. HF and T2D patients were identified and SGLT2I users were propensity score matched to other AGA users. The mean daily dose of loop diuretics in furosemide equivalents was ascertained. For those not on baseline loop diuretics, new use was compared between cohorts. For those on baseline loop diuretics, we assessed patterns of use (increased dose, decreased dose, stable dose, no longer using) at 12-months. RESULTS: A total of 750 SGLT2I users were matched to 750 other AGA users. The distribution of loop diuretic use at mean doses of 0 mg (i.e., no use), ≤20 mg, >20 mg-40 mg, >40 mg-80 mg and >80 mg/day did not differ between cohorts at baseline or 12-months (p > 0.05 for both). SGLT2I use was associated with less new loop diuretic use (22.7% [79/348] vs. 34.0% [132/388]; p = 0.001). For those on loop diuretics at baseline (n = 764), patterns of use at 12-months did not differ between cohorts (p = 0.14). CONCLUSIONS: New loop diuretic use was less frequent among SGLT2I users; however, patterns of loop diuretic use did not differ between cohorts in those on loop diuretics at baseline.

Racial and sex disparities in utilization rates for shoulder arthroplasty in the United States disparities in shoulder arthroplasty.

PURPOSE: To investigate racial disparities in shoulder arthroplasty (SA), accounting for demographic factors such as sex and age. METHODS: Data for SAs (2011-2014) was queried from the Healthcare Cost and Utilization Project Nationwide Inpatient Sample. Population-adjusted SA utilization rates, racial and sex differences by age, length of stay, insurer, and comorbidities were calculated. RESULTS: Caucasians aged 45-64 are 54% more likely than African-Americans and 74% than Hispanics to receive surgery. For patients aged 65-84, the disparity is wider for African-Americans and narrower for Hispanics. CONCLUSIONS: Policymakers and physicians should focus on further national efforts to alleviate healthcare disparities.

Anatomic, Visual, and Financial Outcomes for Traditional and Nontraditional Primary Pneumatic Retinopexy for Retinal Detachment.

PURPOSE: To determine factors predictive of anatomic, visual, and financial outcomes after traditional and nontraditional primary pneumatic retinopexy (PR) for rhegmatogenous retinal detachment (RD). DESIGN: Retrospective interventional case series and cost comparison. METHODS: Participants: Total of 178 eyes (156 patients) with PR-repaired primary RD by a single surgeon at a clinical practice from January 2001 to December 2013 and followed for ≥1 year. The cohort had 2 subgroups: traditional (TPR) and nontraditional (NTPR) PR. MAIN OUTCOME MEASURES: Characteristics associated with best-corrected visual acuity (BCVA) and anatomic outcomes. Cost analysis and potential cost savings comparing PR to scleral buckle and vitrectomy. RESULTS: One hundred thirty-one of 178 eyes (73.5%) were successfully treated at 1 year (postoperative year 1): 72.8% (75/103) in TPR and 74.6% (56/75) in NTPR. Macula-off detachment (-0.44 logMAR, P < .001) and clock hours of RD (-0.84 logMAR, P < .001) correlated with improved BCVA; pseudophakia (0.26 logMAR, P = .002) and inferior retinal tears (0.62 logMAR, P = .009) correlated with worsening BCVA. Pseudophakia (-0.15, P = .03), inferior quadrant RD (-0.27, P < .001), and proliferative vitreoretinopathy (-0.68, P < .001) correlated with anatomic failure. Total average cost for TPR and NTPR was $1248.37 ± $882.11 and $1471.91 ± $942.84, respectively (P = .10). PR had a potential cost savings of 62% and 60.8% when compared to scleral buckle and vitrectomy, respectively. CONCLUSIONS: PR results in successful anatomic and visual outcomes in both TPR and NTPR repair of primary RD. Preoperative pseudophakia is associated with worse visual outcomes and less anatomic success. The cost of primary PR and subsequent procedures to achieve final anatomic success was not significantly different between TPR and NTPR, and supports the possible cost-effectiveness of expanded indications for PR.

A longitudinal examination of the asthma medication ratio in children.

OBJECTIVES: The asthma medication ratio (AMR) (number of controller medications / [number of controller medications + number of rescue medications]) can be calculated using claims data. This measure has not previously been studied longitudinally. Our objective is to conduct a longitudinal examination of the AMR in a large national cohort of children with asthma. STUDY DESIGN: Retrospective analysis of pharmacy and medical claims data. METHODS: Using 2013-2014 TruvenHealth MarketScan data, we identified children with asthma. Beginning with the month of first controller claim, we calculated an AMR for each rolling 3-month period and each rolling 6-month period and examined the proportion who had AMRs classified as low-risk (≥0.5), high-risk (<0.5), and missing for each period. Using logistic regression, we tested how a rolling AMR predicted a child's hospitalization or emergency department (ED) visit for asthma. RESULTS: We identified 197,316 patients aged 2 to 17 years with a claim for a controller. AMRs were relatively stable over time, with the majority of patients remaining in the same AMR category through a 12-month period. Using both the rolling 3-month and 6-month AMRs, a higher proportion of patients with high-risk AMRs (9.6% and 9.5%, respectively) had an ED visit or hospitalization compared with patients with low-risk (5.0% and 5.7%) and missing (3.5% and 3.2%) AMRs (P <.0001). Using logistic regression, the 3-month AMR is more strongly associated with subsequent ED visit or hospitalization than the 6-month AMR. CONCLUSIONS: AMR-based risk assignment is relatively stable over time. Three-month AMR calculation periods appear to provide the most accurate assessment of risk. Children with missing AMRs likely have inactive asthma and are at the lowest risk for emergent asthma visits.