Assessment of Advanced Diagnostic Bronchoscopy Outcomes for Peripheral Lung Lesions: A Delphi Consensus Definition of Diagnostic Yield and Recommendations for Patient-centered Study Designs. An Official American Thoracic Society/American College of Chest Physicians Research Statement.

Background: Advanced diagnostic bronchoscopy targeting the lung periphery has developed at an accelerated pace over the last two decades, whereas evidence to support introduction of innovative technologies has been variable and deficient. A major gap relates to variable reporting of diagnostic yield, in addition to limited comparative studies. Objectives: To develop a research framework to standardize the evaluation of advanced diagnostic bronchoscopy techniques for peripheral lung lesions. Specifically, we aimed for consensus on a robust definition of diagnostic yield, and we propose potential study designs at various stages of technology development. Methods: Panel members were selected for their diverse expertise. Workgroup meetings were conducted in virtual or hybrid format. The cochairs subsequently developed summary statements, with voting proceeding according to a modified Delphi process. The statement was cosponsored by the American Thoracic Society and the American College of Chest Physicians. Results: Consensus was reached on 15 statements on the definition of diagnostic outcomes and study designs. A strict definition of diagnostic yield should be used, and studies should be reported according to the STARD (Standards for Reporting Diagnostic Accuracy Studies) guidelines. Clinical or radiographic follow-up may be incorporated into the reference standard definition but should not be used to calculate diagnostic yield from the procedural encounter. Methodologically robust comparative studies, with incorporation of patient-reported outcomes, are needed to adequately assess and validate minimally invasive diagnostic technologies targeting the lung periphery. Conclusions: This American Thoracic Society/American College of Chest Physicians statement aims to provide a research framework that allows greater standardization of device validation efforts through clearly defined diagnostic outcomes and robust study designs. High-quality studies, both industry and publicly funded, can support subsequent health economic analyses and guide implementation decisions in various healthcare settings.

Evaluation of the Factors Affecting Higher Hospitalization Cost of Lung Resection for Primary Lung Cancer: A Retrospective Cohort Study.

PURPOSE: This study aims to evaluate the factors associated with the higher hospitalization cost of lung resection for primary lung cancer to contribute to the reduction of healthcare spending. METHODS: A total of 435 consecutive primary lung cancer patients who underwent lung resection by a single surgeon at a single institution were enrolled. Baseline patient characteristics, operative procedures, postoperative complications, and postoperative courses were analyzed in relation to the hospitalization cost. Patients with higher costs (exceeding the third quartile [TQ]) were compared with patients with lower costs (less than TQ). RESULTS: Median and TQ medical costs for overall cases were 11177 US dollars (USD) and 12292 USD, respectively. Smoking history, history of coronary artery disease, previous thoracotomy, multiple sealant material use, transfusion, tumor factor T3 or higher, squamous cell carcinoma, postoperative complications, and longer postoperative hospital stay (>10 POD) were significant risk factors for increased hospitalization cost in multivariate analysis. The 5-year survival rate was significantly lower in the higher hospitalization cost group. CONCLUSION: In addition to postoperative complications and prolonged hospitalization, patient background, histological types, and intraoperative factors were also considered as the risk factors for higher medical costs.

Neuropsychiatric sequelae of long COVID-19: Pilot results from the COVID-19 neurological and molecular prospective cohort study in Georgia, USA.

Background: As the coronavirus disease 2019 (COVID-19) pandemic continues, there has been a growing interest in the chronic sequelae of COVID-19. Neuropsychiatric symptoms are observed in the acute phase of infection, but there is a need for accurate characterization of how these symptoms evolve over time. Additionally, African American populations have been disproportionately affected by the COVID-19 pandemic. The COVID-19 Neurological and Molecular Prospective Cohort Study in Georgia (CONGA) was established to investigate the severity and chronicity of these neurologic findings over the five-year period following infection. Methods: The CONGA study aims to recruit COVID-19 positive adult patients in Georgia, United States from both the inpatient and outpatient setting, with 50% being African American. This paper reports our preliminary results from the baseline visits of the first 200 patients recruited who were on average 125 days since having a positive COVID-19 test. The demographics, self-reported symptoms, comorbidities, and quantitative measures of depression, anxiety, smell, taste, and cognition were analyzed. Cognitive measures were compared to demographically matched controls. Blood and mononuclear cells were drawn and stored for future analysis. Results: Fatigue was the most reported symptom in the study cohort (68.5%). Thirty percent of participants demonstrated hyposmia and 30% of participants demonstrated hypogeusia. Self-reported neurologic dysfunction did not correlate with dysfunction on quantitative neurologic testing. Additionally, self-reported symptoms and comorbidities were associated with depression and anxiety. The study cohort performed worse on cognitive measures compared to demographically matched controls, and African American patients scored lower compared to non-Hispanic White patients on all quantitative cognitive testing. Conclusion: Our results support the growing evidence that there are chronic neuropsychiatric symptoms following COVID-19 infection. Our results suggest that self-reported neurologic symptoms do not appear to correlate with associated quantitative dysfunction, emphasizing the importance of quantitative measurements in the complete assessment of deficits. Self-reported symptoms are associated with depression and anxiety. COVID-19 infection appears to be associated with worse performance on cognitive measures, though the disparity in score between African American patients and non-Hispanic White patients is likely largely due to psychosocial, physical health, and socioeconomic factors.

Multiple sclerosis: Frequency, cost, and economic burden in the United States.

Multiple sclerosis (MS) is one of the most common neurological diseases, affecting young and middle-aged adults. The full economic cost of managing chronic MS is substantial. To investigate the recent trend of medical cost and economic burden of MS management in the United States (U.S.), we inquired for available data from the National Inpatient Sample database (NIS; from 1994 to 2013). The annual rates of changes were determined by linear regression analysis. We found an estimated half million increase in MS admissions, annually, which was projected to exceed 43.5 million by the end of year 2017. We also found the charge and the costs associated with MS care increased at rates of US$ 40 million a year and US$ 8 million a year, respectively. We revealed a 1.6 fold increase in the inflation of medical bill in the past decade, and the inflation of medical bills was inversely correlated to the cost-to-charge ratios. In sum, we outline the national trends of medical care use and the expenditure of caring for patients with MS. Periodic reviews and characterizations of expenditure trends are critical for formulating future policy.

Development and Validation of a Method to Identify Children With Social Complexity Risk Factors.

OBJECTIVES: We sought to develop and validate a method to identify social complexity risk factors (eg, limited English proficiency) using Minnesota state administrative data. A secondary objective was to examine the relationship between social complexity and caregiver-reported need for care coordination. METHODS: A total of 460 caregivers of children with noncomplex chronic conditions enrolled in a Minnesota public health care program were surveyed and administrative data on these caregivers and children were obtained. We validated the administrative measures by examining their concordance with caregiver-reported indicators of social complexity risk factors using tetrachoric correlations. Logistic regression analyses subsequently assessed the association between social complexity risk factors identified using Minnesota's state administrative data and caregiver-reported need for care coordination, adjusting for child demographics. RESULTS: Concordance between administrative and caregiver-reported data was moderate to high (correlation range 0.31-0.94, all P values <.01), with only current homelessness (r = -0.01, P = .95) failing to align significantly between the data sources. The presence of any social complexity risk factor was significantly associated with need for care coordination before (unadjusted odds ratio = 1.65; 95% confidence interval, 1.07-2.53) but not after adjusting for child demographic factors (adjusted odds ratio = 1.53; 95% confidence interval, 0.98-2.37). CONCLUSIONS: Social complexity risk factors may be accurately obtained from state administrative data. The presence of these risk factors may heighten a family's need for care coordination and/or other services for children with chronic illness, even those not considered medically complex.

Pediatric medical complexity algorithm: a new method to stratify children by medical complexity.

OBJECTIVES: The goal of this study was to develop an algorithm based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes for classifying children with chronic disease (CD) according to level of medical complexity and to assess the algorithm's sensitivity and specificity. METHODS: A retrospective observational study was conducted among 700 children insured by Washington State Medicaid with ≥1 Seattle Children's Hospital emergency department and/or inpatient encounter in 2010. The gold standard population included 350 children with complex chronic disease (C-CD), 100 with noncomplex chronic disease (NC-CD), and 250 without CD. An existing ICD-9-CM-based algorithm called the Chronic Disability Payment System was modified to develop a new algorithm called the Pediatric Medical Complexity Algorithm (PMCA). The sensitivity and specificity of PMCA were assessed. RESULTS: Using hospital discharge data, PMCA's sensitivity for correctly classifying children was 84% for C-CD, 41% for NC-CD, and 96% for those without CD. Using Medicaid claims data, PMCA's sensitivity was 89% for C-CD, 45% for NC-CD, and 80% for those without CD. Specificity was 90% to 92% in hospital discharge data and 85% to 91% in Medicaid claims data for all 3 groups. CONCLUSIONS: PMCA identified children with C-CD (who have accessed tertiary hospital care) with good sensitivity and good to excellent specificity when applied to hospital discharge or Medicaid claims data. PMCA may be useful for targeting resources such as care coordination to children with C-CD.

Hospital costs and inpatient mortality among children undergoing surgery for congenital heart disease.

OBJECTIVE: To determine the association between hospital costs and risk-adjusted inpatient mortality among children undergoing surgery for congenital heart disease (CHD) in U.S. acute-care hospitals. DATA SOURCES/STUDY SETTINGS: Retrospective cohort study of 35,446 children in 2003, 2006, and 2009 Kids' Inpatient Database (KID). STUDY DESIGN: Cross-sectional logistic regression of risk-adjusted inpatient mortality and hospital costs, adjusting for a variety of patient-, hospital-, and community-level confounders. DATA COLLECTION/EXTRACTION METHODS: We identified relevant discharges in the KID using the AHRQ Pediatric Quality Indicator for pediatric heart surgery mortality, and linked these records to hospital characteristics from American Hospital Association Surveys and community characteristics from the Census. PRINCIPAL FINDINGS: Children undergoing CHD surgery in higher cost hospitals had lower risk-adjusted inpatient mortality (p=.002). An increase from the 25th percentile of treatment costs to the 75th percentile was associated with a 13.6 percent reduction in risk-adjusted mortality. CONCLUSIONS: Greater hospital costs are associated with lower risk-adjusted inpatient mortality for children undergoing CHD surgery. The specific mechanisms by which greater costs improve mortality merit further exploration.

Impact of palivizumab on RSV hospitalizations for children with hemodynamically significant congenital heart disease.

The objective of this study was to evaluate the impact of palivizumab prophylaxis on respiratory syncytial virus (RSV) hospitalizations among children with hemodynamically significant congenital heart disease (CHD). In 2003, the American Academy of Pediatrics (AAP) revised the bronchiolitis policy statement and recommended the use of palivizumab in children <24 months old with hemodynamically significant CHD (HS-CHD). California statewide hospital discharge data from years 2000-2002 (pre-AAP policy revision) were compared to those from years 2004-2006 (post-AAP policy revision). Hospitalizations due to RSV bronchiolitis for children <2 years of age were identified by IDC-9 CM codes 4661.1, 480.1, and 079.6 as the Principal Diagnosis. Children with CHD and children with HS-CHD were identified by the codiagnoses. The overall RSV hospitalization rate was 71 per 10,000 children <2 years of age. Of all RSV hospitalizations, 3.0% were among children with CHD, and 0.50% among children with HS-CHD. HS-CHD patients accounted for 0.56% of RSV hospitalizations in 2000-2002, compared to 0.46% RSV hospitalizations in 2004-2006. That represents a 19% reduction in RSV hospitalizations among HS-CHD patients after 2003. The 19% decrease in RSV hospitalizations equates to seven fewer hospitalizations (76 hospital days) per year among HS-CHD patients. We conclude that, since the recommendation of palivizumab for children with HS-CHD in 2003, the impact on RSV hospitalizations in California among HS-CHD patients has been limited. Considering the high cost of palivizumab administration, the cost-benefit of RSV prophylaxis with palivizumab warrants further investigation.

Dispensing pattern of generic and brand-name drugs in children.

OBJECTIVE: To describe the dispensing patterns of generic and brand-name drugs in children and to identify patient sociodemographic characteristics associated with generic drug use. METHODS: We analyzed data from the 2002 Medical Expenditures Panel Survey. This survey is conducted by the Agency for Healthcare Research and Quality and consists of a nationally representative sample of civilian noninstitutionalized population of the United States. The 2002 survey included 14 828 families and 37 418 individuals, 11 099 of whom were children 0 to 17 years of age. Our unit of analysis was individual prescription drugs dispensed to children 0 to 17 years of age. The main dependent variable for the logistic model was the use of generic drugs. Independent variables included age, gender, race, insurance type, family income, Metropolitan Statistical Area status, and health status. RESULTS: Generic drugs were filled in 40.6% of the 24 465 prescriptions analyzed. Average expenditure for generic drugs was $20.92 (SD 24.53) per prescription versus $71.65 (SD $170.22) for brand-name drugs. Use of generic versus brand-name drugs varied by conditions and medication class. Uninsured patients were more likely than privately insured patients to have a generic drug dispensed than brand-name drugs (odds ratio [OR] 1.42; 95% confidence interval [CI], 1.10-1.84). Asian children were more likely than white children to receive generic drugs (OR, 1.66; 95% CI, 1.07-2.57). Girls were also more likely than boys to receive generic drugs over brand-name drugs (OR, 1.36; 95% CI, 1.08-1.73). CONCLUSIONS: Generic drugs were dispensed more often to uninsured children, Asian children, and girls.

Family structure and the treatment of childhood asthma.

BACKGROUND: Family structure is known to influence children's behavioral, educational, and cognitive outcomes, and recent studies suggest that family structure affects children's access to health care as well. However, no study has addressed whether family structure is associated with the care children receive for particular conditions or with their physical health outcomes. OBJECTIVE: To assess the effects of family structure on the treatment and outcomes of children with asthma. METHODS: Our data sources were the 1996-2003 Medical Expenditure Panel Survey (MEPS) and the 2003 National Survey of Children's Health (NSCH). The study samples consisted of children 2-17 years of age with asthma who lived in single-mother or 2-parent families. We assessed the effect of number of parents and number of other children in the household on office visits for asthma and use of asthma medications using negative binomial regression, and we assessed the effect of family structure on the severity of asthma symptoms using binary and ordinal logistic regression. Our regression models adjusted for sociodemographic characteristics, parental experience in child-rearing and in caring for an asthmatic child and, when appropriate, measures of children's health status. RESULTS: Asthmatic children in single-mother families had fewer office visits for asthma and filled fewer prescriptions for controller medications than children with 2 parents. In addition, children living in families with 3 or more other children had fewer office visits and filled fewer prescriptions for reliever and controller medications than children living with no other children. Children from single-mother families had more health difficulties from asthma than children with 2 parents, and children living with 2 or more other children were more likely to have an asthma attack in the past 12 months than children living with no other children. CONCLUSIONS: For children with asthma, living with a single mother and the presence of additional children in the household are associated with less treatment for asthma and worse asthma outcomes.

Primary language and receipt of recommended health care among Hispanics in the United States.

BACKGROUND: Disparities in health care services between Hispanics and whites in the United States are well documented. OBJECTIVE: The objective of the study was to determine whether language spoken at home identifies Hispanics at risk for not receiving recommended health care services. DESIGN: The design of the study was cross-sectional, nationally representative survey of households. PATIENTS: The patients were non-Hispanic white and Hispanic adults participating in the 2003 Medical Expenditure Panel Survey. MEASUREMENTS: We compared receipt of ten recommended health care services by ethnicity and primary language adjusting for demographic and socioeconomic characteristics, health status, and access to care. RESULTS: The sample included 12,706 whites and 5,500 Hispanics. In bivariate comparisons, 57.0% of whites received all eligible health care services compared to 53.6% for Hispanics who spoke English at home, 44.9% for Hispanics who did not speak English at home but who were comfortable speaking English, and 35.0% for Hispanics who did not speak English at home and were uncomfortable speaking English (p < .001). In multivariate logistic models, compared to non-Hispanic whites, Hispanics who did not speak English at home were less likely to receive all eligible health care services, whether they were comfortable speaking English (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74-0.97) or not (RR 0.84, 95% CI 0.68-0.95). CONCLUSIONS: Speaking a language other than English at home identified Hispanics at risk for not receiving recommended health care services, whether they were comfortable in speaking English or not. Identifying the mechanism for disparities by language usage may lead to interventions to reduce ethnic disparities.

Preventive health care for children with and without special health care needs.

OBJECTIVE: The objective of this study was to compare the receipt of preventive health services for children with and without special health care needs and to identify predictors of these health services for children with special health care needs using nationally representative data. METHODS: Data from the 2002 and 2003 Medical Expenditure Panel Surveys were analyzed. A total of 18,279 children aged 3 to 17 years were included in our study. The Child Preventive Health Supplement was used to identify caregiver recall of specific health screening measures and anticipatory guidance during the previous 12 months. Odds ratios were calculated for predictive factors of preventive services for children with special health care needs. RESULTS: The prevalence of special health care needs in children aged 3 to 17 years was 21.6%. Based on caregiver reports, 87.5% of children with special health care needs had > or = 1 health screening measure checked in the past year compared with 73.1% of children without special health care needs. Receipt of > or = 1 topic of anticipatory guidance was reported for 69.8% of children with special health care needs compared with 55.2% of children without special health care needs. Black and Hispanic caregivers of children with special health care needs were more likely than others to report receipt of all 6 categories of anticipatory guidance measured in this study. CONCLUSIONS: We found that caregivers of children with special health care needs were more likely to report receipt of anticipatory guidance and health screening than were caregivers of children without special health care needs. Although a majority of these caregivers reported receiving some health screening and anticipatory guidance on an annual basis, there are clear gaps in the delivery of preventive health services. This study identifies areas for improvement in the delivery of preventive health services for children with special health care needs and children in general.

Effects of family structure on children's use of ambulatory visits and prescription medications.

OBJECTIVE: To examine the effects of family structure, including number of parents, number of other children, and number and type of other adults, on office visits, emergency room visits, and use of prescription medications by children. DATA SOURCE: The Household Component of the 1996-2001 Medical Expenditure Panel Survey (MEPS). STUDY DESIGN: The study consisted of a nationally representative sample of children 0-17 years of age living in single-mother or two-parent families. We used negative binomial regression to model office visits and emergency room visits and logistic regression to model the likelihood of prescription medication use. Our analyses adjusted for demographic and socioeconomic characteristics as well as measures of children's health and parental education and child-rearing experience. DATA COLLECTION/EXTRACTION METHOD: We combined 1996-2001 MEPS Full Year Consolidated Files and Medical Conditions Files. PRINCIPAL FINDINGS: Descriptive data showed that children in single-mother families had fewer office visits than children in two-parent families; however, the effect of number of parents in the family on children's office visits or use of prescription medications was completely explained by other explanatory variables. By contrast, children living in families with many other children had fewer total and physician office visits and a lower likelihood of using a prescription medication than children living in families with no other children even after adjusting for other explanatory variables. Children who lived with other adults in addition to their parents also had fewer office visits and a lower likelihood of using a prescription medication than children who lived only with their parents. CONCLUSIONS: Children living in families with many other children or with other adults use less ambulatory care and prescription medications than their peers. Additional research is needed to determine whether these differences in utilization affect children's health.

Insurance coverage and financial burden for families of children with special health care needs.

OBJECTIVE: To examine the role of insurance coverage in protecting families of children with special health care needs (CSHCN) from the financial burden associated with care. METHODS: Data from the 2001 National Survey of Children with Special Health Care Needs were analyzed. We built 2 multivariate regression models by using "work loss/cut back" and "experiencing financial problems" as the dependent variables, and insurance status as the primary independent variable of interest while adjusting for income, race/ethnicity, functional limitation/severity, and other sociodemographic predictors. RESULTS: Approximately 29.9% of CSHCN live in families where their condition led parents to report cutting back on work or stopping work completely. Families of 20.9% of CSHCN reported experiencing financial difficulties due to the child's condition. Insurance coverage significantly reduced the likelihood of financial problems for families at every income level. The proportion of families experiencing financial problems was reduced from 35.7% to 23.0% for the poor and 44.9% to 24.5% for low-income families with continuous insurance coverage (P < .01 for both comparisons). Similarly, the proportion of parents having to cut back or stop work was reduced from 42.8% to 35.9% for the poor (P < .05) and 43.5% to 33.9% for low-income families (P < .01). CONCLUSIONS: Continuous health insurance coverage provides protection from financial burden and hardship for families of CSHCN in all income groups. This evidence is supportive of policies designed to promote universal coverage for CSHCN. However, many poor and low-income families continue to experience work loss and financial problems despite insurance coverage. Hence, health insurance should not be viewed as a solution in itself, but instead as one element of a comprehensive strategy to provide financial safety for families with CSHCN.

Changes in the newborn delivery practice and neonatal outcomes as financing changed in Los Angeles County and Orange County, California.

The objective of this investigation was to study changes in newborn delivery during a period of extensive changes in financing mechanisms in Los Angeles County (LAC) and Orange County (OC), California. California hospital discharge data (1990-1999) were used for the analyses. The Herfindahl-Hirschman Index (HHI) was calculated to measure the distribution of newborn deliveries among hospitals. Birth outcomes, including cesarean section rates, in-hospital deaths, interhospital transfers, and selected neonatal morbidities, were assessed. A total of 2,351,209 newborn deliveries in 124 hospitals were recorded. The number of newborn babies delivered per year decreased by 21% during the study period. A dramatic decline in the number of deliveries (up to 80%) was seen in all four LAC county hospitals. The cesarean section rate increased for Medi-Cal patients during the study period, compared with no change in the rate for privately insured patients. The newborn interhospital transfer rate for patients in LAC remained unchanged. The newborn in-hospital mortality rates for both LAC and OC decreased during the study period.

Private dental and prescription-drug coverage in children: data from the medical expenditure panel survey.

OBJECTIVE: Most studies on health insurance have examined primarily basic medical insurance coverage; few have looked at supplemental insurance and/or dental-insurance coverage. Prescription-drug and dental-insurance coverage are becoming increasingly important due to continued increase in health care costs and changes in cost-sharing structure of health plans. This study examined prescription-drug coverage and dental-insurance coverage in the context of overall insurance coverage. METHOD: This study utilized the Household Component File from the 2000 Medical Expenditure Panel Survey (MEPS), a national survey on medical care conducted by the Agency for Healthcare Research and Quality (AHRQ). Univariate and bivariate analyses were performed to provide estimates on children's prescription-drug and dental-insurance coverage. Multivariate logistic regression analyses were conducted to identify demographic and socioeconomic factors that influence coverage. RESULTS: In 2000, 68.5% of US children had private insurance, 22.2% had public insurance, and 9.3% were uninsured. Among children with private insurance, only 56.9% had dental-insurance coverage and 76.3% had prescription-drug coverage. Family income level, maternal education, and race were significant predictors of dental insurance and prescription-drug coverage. CONCLUSION: Although significant strides have been made to insure US children, a large percentage of children still do not have comprehensive coverage. Even among privately insured children, many are without dental or prescription-drug coverage. Those who were poor, minority, and with low maternal education had lower likelihood of dental and prescription-drug coverage.

Quantifying income-related inequality in healthcare delivery in the United States.

BACKGROUND: Numerous studies have found that high-income Americans use more medical care than their low-income counterparts, irrespective of medical "need." The methods employed in these studies, however, make it difficult to evaluate differences in the degree of income-related inequality in utilization across population subgroups. In this study, we derive a summary index to quantify income-related inequality in need-adjusted medical care expenditures and report values of the index for adults and children in the United States. METHODS: We used the summary index of income-related inequality in expenditures developed by Wagstaff et al. 1 The source of data for the study was the Household Component of the 1996-1998 Medical Expenditure Panel Survey, which contains person-level data on medical care expenditures, demographic characteristics, household income, and a wide array of health status measures. We used multivariate regression analysis to predict need-adjusted annual medical care expenditures per person by income level and used the predictions to calculate the indices of inequality. Separate indices were calculated for all adults, working-age adults, seniors, and children ages 5 to 17. RESULTS: For all age groups, predicted expenditures per person, adjusted for medical need, generally increased as income rose. The index of inequality for all adults was +0.087 (95% confidence interval, +0.035, +0.139); for working-age adults, +0.099 (+0.046, +0.152); for seniors, +0.147 (+0.059, +0.235); and for children, +0.067 (+0.006, +0.128). CONCLUSIONS: There exists income-related inequality in medical care expenditures in the United States, and it favors the wealthy. The inequality is highest among seniors despite Medicare, intermediate among working-age adults, and lowest among children.

Female sex as a risk factor for in-hospital mortality among children undergoing cardiac surgery.

BACKGROUND: The purpose of this study was to investigate whether sex disparity in cardiovascular outcomes exists in children who undergo cardiac surgery. METHODS AND RESULTS: Statewide hospital discharge data from California from 1995 to 1997 were used. Children <21 years old who had a procedure code (by ICD9-CM) that indicated cardiac surgery were selected. The outcome variable was binary, in-hospital death versus alive at discharge. Twenty-three surgical procedures were selected and adjusted for risk by procedure type. We used logistic regression analysis to evaluate the effect of sex on in-hospital mortality, controlling for age, race and ethnicity, type of insurance, home income, type of admission, date and month of surgery, hospital case volume, and type of procedure. There were 6593 cases of cardiac surgery, with 345 in-hospital deaths (mortality rate 5.23%). Crude mortality rates for males (4.98%) and females (5.54%) were not significantly different. However, fewer females were neonates, and females had more low-risk procedures than males. Multivariate logistic regression showed that females had a higher odds ratio (OR) for mortality than males (OR 1.51, P<0.01). The OR for mortality was 3.86 for neonates and 2.98 for infants compared with children aged > or =1 year. Low-volume hospitals had higher mortality rates than high-volume hospitals (OR 1.67, P<0.01). The risk-adjusted length of hospital stay and charges were similar between females and males. CONCLUSIONS: For children undergoing cardiac surgery, female sex was associated with 51% higher odds of death than male sex. The mechanism by which female sex acts as a risk factor requires further investigation.

Factors associated with prescription drug expenditures among children: an analysis of the Medical Expenditure Panel survey.

OBJECTIVE: Pharmaceutical costs have reached 14% of total health care costs in the United States and continue to rise. Many studies have looked at factors that influence utilization of hospital and ambulatory care services in the pediatric population. This study examines the factors that influence utilization of prescription drugs in the pediatric population. METHODS: Data from the 1996 Medical Expenditure Panel Survey (MEPS) were used in the analysis. A 2-part multivariate regression analysis was conducted using pediatric (ages 0-17) prescription drug expenditures as the dependent variable. Independent variables were constructed using demographic variables, socioeconomic variables, health status, and medical conditions. RESULTS: Black children are less likely than white children to use any prescription drug (odds ratio: 0.67). Similarly, uninsured children are less likely than privately insured children to use any prescription drug (odds ratio: 0.62). Among children who had any prescription drug expenditure in 1996, children who are black, Asian, and Hispanic had lower prescription drug expenditures than children who are white. Children who are uninsured had lower expenditures than children who are privately insured. Children in near-poor families had lower prescription drug expenditures than those in high-income families, even after controlling for insurance status. Children who are covered by Medicaid had comparable prescription drug expenditures to children who are covered by private insurance. CONCLUSION: Socioeconomic characteristics such as race, insurance status, and family income levels had significant impact on pediatric prescription drug expenditures, even after controlling for the influences of health status and medical conditions.