An Empirically Derived Pediatric Cardiac Inotrope Score Associated With Pediatric Heart Surgery.

We aimed to empirically derive an inotrope score to predict real-time outcomes using the doses of inotropes after pediatric cardiac surgery. The outcomes evaluated included in-hospital mortality, prolonged hospital length of stay, and composite poor outcome (mortality or prolonged hospital length of stay). The study population included patients <18 years of age undergoing heart operations (with or without cardiopulmonary bypass) of varying complexity. To create this novel pediatric cardiac inotrope score (PCIS), we collected the data on the highest doses of 4 commonly used inotropes (epinephrine, norepinephrine, dopamine, and milrinone) in the first 24 hours after heart operation. We employed a hierarchical framework by representing discrete probability models with continuous latent variables that depended on the dosage of drugs for a particular patient. We used Bayesian conditional probit regression to model the effects of the inotropes on the mean of the latent variables. We then used Markov chain Monte Carlo simulations for simulating posterior samples to create a score function for each of the study outcomes. The training dataset utilized 1030 patients to make the scientific model. An online calculator for the tool can be accessed at https://soipredictiontool.shinyapps.io/InotropeScoreApp. The newly proposed empiric PCIS demonstrated a high degree of discrimination for predicting study outcomes in children undergoing heart operations. The newly proposed empiric PCIS provides a novel measure to predict real-time outcomes using the doses of inotropes among children undergoing heart operations of varying complexity.

A prognostic tool to predict outcomes in children undergoing the Norwood operation.

OBJECTIVES: To create and validate a prediction model to assess outcomes associated with the Norwood operation. METHODS: The public-use dataset from a multicenter, prospective, randomized single-ventricle reconstruction trial was used to create this novel prediction tool. A Bayesian lasso logistic regression model was used for variable selection. We used a hierarchical framework by representing discrete probability models with continuous latent variables that depended on the risk factors for a particular patient. Bayesian conditional probit regression and Markov chain Monte Carlo simulations were then used to estimate the effects of the predictors on the means of these latent variables to create a score function for each of the study outcomes. We also devised a method to calculate the risk of outcomes associated with the Norwood operation before the actual heart operation. The 2 study outcomes evaluated were in-hospital mortality and composite poor outcome. RESULTS: The training dataset used 520 patients to generate the prediction model. The model included patient demographics, baseline characteristics, cardiac diagnosis, operation details, site volume, and surgeon experience. An online calculator for the tool can be accessed at https://soipredictiontool.shinyapps.io/NorwoodScoreApp/. Model validation was performed on 520 observations using an internal 10-fold cross-validation approach. The prediction model had an area under the curve of 0.77 for mortality and 0.72 for composite poor outcome on the validation dataset. CONCLUSIONS: Our new prognostic tool is a promising first step in creating real-time risk stratification in children undergoing a Norwood operation; this tool will be beneficial for the purposes of benchmarking, family counseling, and research.

Relationship of Hospital Costs With Mortality in Pediatric Critical Care: A Multi-Institutional Analysis.

OBJECTIVE: With increasing emphasis on high "value" care, we designed this study to evaluate the relationship between hospital costs and patient outcomes in pediatric critical care. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information Systems. Multivariable mixed effects logistic regression models were fitted to evaluate association of hospital cost tertiles with odds of mortality after adjusting for patient and center characteristics. SETTING: Forty-seven children's hospitals across the United States. PATIENTS: Patients 18 years old or younger admitted to a PICU at a Pediatric Health Information Systems participating hospital were included (2004-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 917,663 patients from 47 hospitals were included. Median cost per patient was $42,181 in the low-cost hospitals (341,689 patients, 16 hospitals), $56,806 in the middle-cost hospitals (310,293 patients, 16 hospitals), and $82,588 in the high-cost hospitals (265,681 patients, 15 hospitals). In unadjusted analysis, patients cared for in the high-cost tertile hospitals were younger in age, associated with more comorbidities, had higher resource utilization (including extracorporeal membrane oxygenation and nitric oxide), had higher prevalence of cardiac arrest, and were associated with worse outcomes (including mortality). In adjusted analysis, high-cost tertile hospitals were not associated with improved mortality, when compared with low- and medium-cost tertile hospitals (low cost vs high cost: odds ratio, 0.99; 95% CI, 0.79-1.25 and middle cost vs high cost: odds ratio, 1.10; 95% CI, 0.86-1.41). When stratified by diagnoses category, we noted similar trends among cardiac and noncardiac patients. CONCLUSIONS: This large observational study did not demonstrate any relationship between hospital costs and patient outcomes in children with critical illness. Further efforts are needed to evaluate quality-cost relationship and high value care in critically ill children across centers of varying volume by linking data from clinical and administrative databases.

Effect of Inhaled Nitric Oxide on Outcomes in Children With Acute Lung Injury: Propensity Matched Analysis From a Linked Database.

OBJECTIVES: To evaluate the effect of inhaled nitric oxide on outcomes in children with acute lung injury. DESIGN: Retrospective study with a secondary data analysis of linked data from two national databases. Propensity score matching was performed to adjust for potential confounding variables between patients who received at least 24 hours of inhaled nitric oxide (inhaled nitric oxide group) and those who did not receive inhaled nitric oxide (no inhaled nitric oxide group). SETTING: Linked data from Virtual Pediatric Systems (LLC) database and Pediatric Health Information System. PATIENTS: Patients less than 18 years old receiving mechanical ventilation for acute lung injury at nine participating hospitals were included (2009-2014). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 20,106 patients from nine hospitals were included. Of these, 859 patients (4.3%) received inhaled nitric oxide for at least 24 hours during their hospital stay. Prior to matching, patients in the inhaled nitric oxide group were younger, with more comorbidities, greater severity of illness scores, higher prevalence of cardiopulmonary resuscitation, and greater resource utilization. Before matching, unadjusted outcomes, including mortality, were worse in the inhaled nitric oxide group (inhaled nitric oxide vs no inhaled nitric oxide; 25.7% vs 7.9%; p < 0.001; standardized mortality ratio, 2.6 [2.3-3.1] vs 1.1 [1.0-1.2]; p < 0.001). Propensity score matching of 521 patient pairs revealed no difference in mortality in the two groups (22.3% vs 20.2%; p = 0.40; standardized mortality ratio, 2.5 [2.1-3.0] vs 2.3 [1.9-2.8]; p = 0.53). However, the other outcomes such as ventilation free days (10.1 vs 13.6 d; p < 0.001), duration of mechanical ventilation (13.8 vs 10.1 d; p < 0.001), duration of ICU and hospital stay (15.5 vs 12.2 d; p < 0.001 and 28.0 vs 24.1 d; p < 0.001), and hospital costs ($150,569 vs $102,823; p < 0.001) were significantly worse in the inhaled nitric oxide group. CONCLUSIONS: This large observational study demonstrated that inhaled nitric oxide administration in children with acute lung injury was not associated with improved mortality. Rather, it was associated with increased hospital utilization and hospital costs.

Association of house staff training with mortality in children with critical illness.

AIM: To evaluate the association of house staff training with mortality in children with critical illness. METHODS: Patients <18 years of age in the Virtual PICU Systems (VPS, LLC) Database (2009-2013) were included. The study population was divided in two study groups: hospitals with residency programme only and hospitals with both residency and fellowship programme. Control group constituted hospitals with no residency or fellowship programme. The primary study outcome was mortality before intensive care unit (ICU) discharge. Multivariable logistic regression models were fitted to evaluate association of training programmes with ICU mortality. RESULTS: A total of 336 335 patients from 108 centres were included. Case-mix of patients among the hospitals with training programmes was complex; patients cared for in the hospitals with training programmes had greater severity of illness, had higher resource utilisation and had higher overall admission risk of death compared to patients cared for in the control hospitals. Despite caring for more complex and sicker patients, the hospitals with training programmes were associated with lower odds of ICU mortality. CONCLUSION: Our study establishes that ICU care provided in hospitals with training programmes is associated with improved adjusted survival rates among the Virtual PICU database hospitals in the United States.

Outcomes associated with preoperative use of extracorporeal membrane oxygenation in children undergoing heart operation for congenital heart disease: a multi-institutional analysis.

BACKGROUND: There are very sparse data on patient outcomes related to the use of extracorporeal membrane oxygenation (ECMO) prior to heart operation in children with congenital heart disease. This study was designed to evaluate this association using the Pediatric Health Information System (PHIS) database. HYPOTHESIS: We hypothesize that patients receiving ECMO prior to heart operation will have worse outcomes, including mortality, compared with patients receiving ECMO after heart operation. METHODS: Patients age ≤18 years receiving ECMO before or after pediatric heart operation (with or without cardiopulmonary bypass) at a PHIS-participating hospital from 2004 to 2013 were included. Multivariable logistic regression or Cox proportional-hazards models were fitted to study the effect of timing of ECMO initiation in relation to cardiac surgery on study outcomes. RESULTS: A total of 3498 patients from 42 hospitals qualified for inclusion. Of these, 494 (14%) received ECMO prior to heart operation (presurgery ECMO) and 3004 (86%) received ECMO after heart operation (postsurgery ECMO). Unadjusted mortality was significantly lower in the presurgery ECMO group compared with the postsurgery ECMO group (30% vs 45%; P < 0.0001). After adjusting for patient and center characteristics, odds of mortality were significantly lower in the presurgery ECMO group (odds ratio: 0.46, 95% confidence interval: 0.36-0.59, P < 0.0001). There were no significant differences in ECMO duration, length of hospital stay, and hospital charges between the 2 groups in adjusted models. CONCLUSIONS: This study suggests that ECMO can be used with satisfactory outcomes prior to heart operation in children with congenital heart disease.