Neighborhood Income Is Associated with Health Care Use in Pediatric Short Bowel Syndrome.

OBJECTIVE: To evaluate associations between neighborhood income and burden of hospitalizations for children with short bowel syndrome (SBS). STUDY DESIGN: We used the Pediatric Health Information System (PHIS) database to evaluate associations between neighborhood income and hospital readmissions, readmissions for central line-associated bloodstream infections (CLABSI), and hospital length of stay (LOS) for patients <18 years with SBS hospitalized between January 1, 2006, and October 1, 2015. We analyzed readmissions with recurrent event analysis and analyzed LOS with linear mixed effects modeling. We used a conceptual model to guide our multivariable analyses, adjusting for race, ethnicity, and insurance status. RESULTS: We included 4289 children with 16 347 hospitalizations from 43 institutions. Fifty-seven percent of the children were male, 21% were Black, 19% were Hispanic, and 67% had public insurance. In univariable analysis, children from low-income neighborhoods had a 38% increased risk for all-cause hospitalizations (rate ratio [RR] 1.38, 95% CI 1.10-1.72, P = .01), an 83% increased risk for CLABSI hospitalizations (RR 1.83, 95% CI 1.37-2.44, P < .001), and increased hospital LOS (ß 0.15, 95% CI 0.01-0.29, P = .04). In multivariable analysis, the association between low-income neighborhoods and elevated risk for CLABSI hospitalizations persisted (RR 1.70, 95% CI 1.23-2.35, P < .01, respectively). CONCLUSIONS: Children with SBS from low-income neighborhoods are at increased risk for hospitalizations due to CLABSI. Examination of specific household- and neighborhood-level factors contributing to this disparity may inform equity-based interventions.

The influence of neighborhood income on healthcare utilization in pediatric liver transplant.

OBJECTIVES: Neighborhood contextual factors are associated with liver transplant outcomes. We analyzed associations between neighborhood-level socioeconomic status and healthcare utilization for pediatric liver transplant recipients. METHODS: We merged the Pediatric Health Information System and Scientific Registry of Transplant Recipients databases and included liver transplant recipients ≤21 years hospitalized between January 2004 and May 2022. Outcomes were annual inpatient bed-days, risk of hospitalizations, and risk of liver biopsies. The primary exposure was zip code-based neighborhood income at transplant. We applied causal inference for variable selection in multivariable analysis. We modeled annual inpatient bed-days with mixed-effect zero-inflated Poisson regression, and rates of hospitalization and liver biopsy with a Cox-type proportional rate model. RESULTS: We included 1006 participants from 29 institutions. Children from low-income neighborhoods were more likely to be publicly insured (67% vs. 46%), Black (20% vs. 12%), Hispanic (30% vs. 17%), and have higher model for end-stage liver disease/pediatric end-stage liver disease model scores at transplant (17 vs. 13) than the remaining cohort. We found no differences in inpatient bed-days or rates of hospitalization across neighborhood groups. In univariable analysis, low-income neighborhoods were associated with increased rates of liver biopsy (rate ratio [RR]: 1.57, 95% confidence interval [CI]: 1.04-2.34, p = 0.03). These findings persisted after adjusting for insurance, race, and ethnicity (RR: 1.86, 95% CI: 1.23-2.83, p < 0.01). CONCLUSIONS: Children from low-income neighborhoods undergo more liver biopsies than other children. These procedures are invasive and potentially preventable. In addition to improving outcomes, interventions to mitigate health inequities among liver transplant recipients may reduce resource utilization.

The Relationship Between Prematurity, Method of Delivery, and Functional Gastrointestinal Disorders in Children.

OBJECTIVE: The pathogenesis of functional gastrointestinal disorders (FGIDs) remains unknown. Early life events including method of delivery and length of gestation may be risk factors for FGIDs. Data from studies on early life events and the development of FGIDs are scarce and contradictory. OBJECTIVE: The aim of the study was to assess the association between mode of delivery, length of gestation, and FGIDs in children. We hypothesized that delivery via Cesarean section and prematurity would be associated with an increased prevalence of FGIDs. METHODS: Questionnaires were mailed to families from 3 cities in Colombia. Parents provided information on mode of delivery, demographics, and medical history. School children completed the Spanish version of the Questionnaire of Pediatric Gastrointestinal Symptoms Rome IV. Categorical data were analyzed using Fisher exact tests. Calculation of odds ratio with 95% confidence interval was performed. RESULTS: A total of 1497 children (535 preadolescents 10-12 years, 962 adolescents 13-18 years) participated. For participants born via Cesarean delivery, there was no significant increase in prevalence of any of the Rome IV FGIDs compared with vaginal delivery. There was a significant association between prematurity and FGIDs for those born between 28 and 32 weeks (confidence interval 0.99-3.37; P = 0.03). In this group, functional nausea was the only category of FGID to reach significance (0.16-112.23) (P = 0.02). However, statistical significance was lost when gestational ages were grouped together with multivariate analysis. CONCLUSIONS: Our findings provide evidence that Cesarean delivery and prematurity are not risk factors for the development of FGIDs. Future studies are indicated to further evaluate the relationship between early life events and FGIDs.

Associations between hospital-level socioeconomic patient mix and rates of central line-associated bloodstream infections in short bowel syndrome: A retrospective cohort study.

BACKGROUND: Low neighborhood income is linked with increased hospitalizations for central line-associated bloodstream infections (CLABSIs) in pediatric short bowel syndrome (SBS). We assessed whether this relationship varies by hospital center. METHODS: We performed a retrospective cohort study using the Pediatric Health Information System (2018-2023) database for patients <18 years old with SBS (N = 1210) at 24 hospitals in the United States. Using 2015 US Census data, we determined the estimated median household income of each patient's zip code. Hospital-level neighborhood income was defined as the median of the estimated median household income among patients at each hospital. We applied an extension of Cox regression to assess risk for CLABSI hospitalization. RESULTS: Among 1210 children with 5255 hospitalizations, most were <1 year on initial admission (53%), male (58%), and publicly insured (69%). Hospitals serving low-income neighborhoods served more female (46% vs 39%), Black (29% vs 22%), and Hispanic (22% vs 16%) patients with public insurance (72% vs 65%) residing in the southern United States (47% vs 21%). In univariate analysis, low hospital-level neighborhood income was associated with increased risk of CLABSI hospitalization (rate ratio [RR], 1.48; 95% CI, 1.21-1.83; P < 0.001). These findings persisted in multivariate analysis (RR, 1.43; 95% CI, 1.10-1.84; P < 0.01) after adjusting for race, ethnicity, insurance, region, and patient-level neighborhood income. CONCLUSION: Hospitals serving predominantly low-income neighborhoods bear a heavier burden of CLABSI hospitalizations for all their patients across the socioeconomic spectrum. Hospital initiatives focused on CLABSI prevention may be pivotal in addressing this disparity.

Automatic detection of patient-ventilator asynchrony by spectral analysis of airway flow.

INTRODUCTION: Adequate ventilatory support of critically ill patients depends on prompt recognition of ventilator asynchrony, as asynchrony is associated with worse outcomes.We compared an automatic method of patient-ventilator asynchrony monitoring, based on airway flow frequency analysis, to the asynchrony index (AI) determined visually from airway tracings. METHODS: This was a prospective, sequential observational study of 110 mechanically ventilated adults. All eligible ventilated patients were enrolled. No clinical interventions were performed. Airway flow and pressure signals were sampled digitally for two hours. The frequency spectrum of the airway flow signal, processed to include only its expiratory phase, was calculated with the Cooley-Tukey Fast Fourier Transform method at 2.5 minute intervals. The amplitude ratio of the first harmonic peak (H1) to that of zero frequency (DC), or H1/DC, was taken as a measure of spectral organization. AI values were obtained at 30-minute intervals and compared to corresponding measures of H1/DC. RESULTS: The frequency spectrum of synchronized patients was characterized by sharply defined peaks spaced at multiples of mean respiratory rate. The spectrum of asynchronous patients was less organized, showing lower and wider H1 peaks and disappearance of higher frequency harmonics. H1/DC was inversely related to AI (n = 110; r2 = 0.57; P < 0.0001). Asynchrony, defined by AI > 10%, was associated H1/DC < 43% with 83% sensitivity and specificity. CONCLUSIONS: Spectral analysis of airway flow provides an automatic, non-invasive assessment of ventilator asynchrony at fixed short intervals. This method can be adapted to ventilator systems as a clinical monitor of asynchrony.

Disparities in the use of antenatal corticosteroids among women with hypertension in North Carolina.

OBJECTIVE: To evaluate antenatal corticosteroids (ANS) use in pregnant women with hypertension. STUDY DESIGN: Retrospective analysis of ANS use in the Perinatal Quality Collaborative of North Carolina between 2015 and 2017. RESULTS: Twenty-five centers participated, with 9% (1580/17,692) of mothers delivering at <34 weeks; of these, 81% (1286/1580) received a full course of ANS, which was not different between phases (p = 0.32), or between Level III/IV neonatal intensive care units (NICUs; 82%), and I/II NICUs (76%) (p = 0.05). In Level III/IV NICUs, White mothers were more likely to receive ANS (87%) than African Americans (77%) or other race/ethnicity (80%) (including Hispanics) (p = 0.001). ANS use did not differ among mothers with different payers (p = 0.94). CONCLUSION: The rates of full ANS courses did not significantly increase from 2015-2017 and disparities persisted. Targeted efforts to improve ANS exposures among hypertensive African American and Hispanic mothers, as well as in community hospital settings are needed.

Timely Delivery of Discharge Medications to Patients' Bedsides: A Patient-centered Quality Improvement Project.

INTRODUCTION: Patients who are unable to fill prescriptions after discharge are at risk of hospital readmission. Ensuring that patients have prescriptions in hand at the time of discharge is a critical component of a safe and effective discharge process. Using a "Meds to Beds" program, we aimed to increase the percentage of patients discharged from Holtz Children's Hospital with medications in hand from 49% to 80%, reduce turnaround time (TAT) from electronic prescription signature to bedside delivery from 4.9 hours (±2.6 hours) to 2 hours, and increase caregiver satisfaction. METHODS: We formed a multidisciplinary team and implemented 4 patient-centered interventions through iterative plan-do-study-act cycles. Statistical process control charts were used to understand the impact of the interventions over 10 months. Hospital length of stay and discharges before 2:00 pm were used as balancing measures. We measured caregiver satisfaction using a telephone survey administered by pediatric residents within 7 days after discharge. RESULTS: The mean percentage of patients discharged with medications in hand increased to 76%. TAT decreased to 3.5 hours (±1.8 hours). Length of stay did not significantly increase, whereas the percentage of patients discharged before 2:00 pm did. Caregivers of patients who had prescriptions delivered to their bedside reported high levels of satisfaction. CONCLUSIONS: Using a "Meds to Beds" program, we increased the percentage of patients discharged with medications in hand, decreased TAT with reduced variability, and achieved high levels of caregiver satisfaction. Importantly, there was a shift in the culture of the institution toward improved medication access for patients.

Implementation and case-study results of potentially better practices for family-centered care: the family-centered care map.

OBJECTIVE: The objective of this study was to enhance the ability to coordinate and deliver care in a holistic manner, through a family-centered care map, so that the developmental, physical, and psychosocial needs of the infant and family are met. METHODS: A Web-based map was based on 7 distinct clinical phases with 3 variations of an infant's course through a NICU. Sixty-three potentially better practices were identified and 7 potentially better practices were implemented through case studies. RESULTS: Measures of family satisfaction revealed improvements in delivery of family-centered care. Increases in discharge growth parameters for extremely low birth weight infants were demonstrated. Length of stay for very low birth weight infants decreased from 73 to 60 days in Vermont. CONCLUSIONS: The collaborative process enhances identification of potentially better practices and results in both qualitative and quantitative improvements in family-centered care.