Repeat Laboratory Testing in the Pediatric Emergency Department: How Often and How Important?

BACKGROUND: Little is known about repeat testing for patients admitted to children's hospitals from the emergency department (ED). OBJECTIVE: The objective of this study was to describe the trend of repeat laboratory testing from a children's hospital ED. METHODS: Laboratory studies were analyzed for July 2002 to June 2010 for complete blood counts (CBCs; 7 years), basic metabolic panels (BMPs; 2.5 years), and coagulation studies (7 years) ordered and reordered in the ED within 8 hours for patients admitted to the hospital. Results for tests were generated and classified into high, low, and normal based on reference ranges. To reflect actual practice, we expanded the normal range from 95% of lower bound to 105% of upper bound. RESULTS: A total of 37,035 CBCs, 11,414 BMPs, and 3903 coagulation studies were ordered. Proportions of these tests repeated were 0.9%, 1.9%, and 1.9%, respectively. Mean time to repeat was 2 hours. For CBCs, 25% of repeats were for a missing component; 35% were for low platelet counts. Sixty-eight percent of initial BMPs were repeated for high potassium. Half of coagulation studies were repeated for high prothrombin time; 36% were repeated for a missing component. On repeat, 75% of BMPs with high potassium levels and 65% of CBCs with low platelet count returned normal values, but 16% of coagulation studies repeated for high prothrombin time returned normal values. CONCLUSIONS: Repeat ED laboratory testing occurs infrequently at a children's hospital, and a large proportion of repeats is attributed to missing results. When repeated, abnormal results on initial studies are often returned as normal.

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

OBJECTIVES: To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models. STUDY DESIGN: We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy. RESULTS: For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals. CONCLUSIONS: We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury.

OBJECTIVE: To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN: Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS: There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS: Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Rates and impact of potentially preventable readmissions at children's hospitals.

OBJECTIVE: To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals. STUDY DESIGN: A total of 1 719 617 hospitalizations for 1 531 828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions. RESULTS: The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year). CONCLUSIONS: Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs.

Patient and hospital factors associated with induction mortality in acute lymphoblastic leukemia.

BACKGROUND: Deaths during induction chemotherapy for pediatric acute lymphoblastic leukemia (ALL) account for one-tenth of ALL-associated mortality and half of ALL treatment-related mortality. We sought to ascertain patient- and hospital-level factors associated with induction mortality. PROCEDURE: We performed a retrospective cohort analysis of 8,516 children ages 0 to <19 years with newly diagnosed ALL admitted to freestanding US children's hospitals from 1999 to 2009 using the Pediatric Health Information System database. Induction mortality risk was modeled accounting for demographics, intensive care unit-level interventions, and socioeconomic status (SES) using Cox regression. The association of ALL induction mortality with hospital-level factors including volume, hospital-wide mortality and payer mix was analyzed with multiple linear regression. RESULTS: ALL induction mortality was 1.12%. Race and patient-level SES factors were not associated with induction mortality. Patients receiving both mechanical ventilation and vasoactive infusions experienced nearly 50% mortality (hazard ratio 122.30, 95% CI 66.56-224.80). Institutions in the highest induction mortality quartile contributed 27% of all patients but nearly half of all deaths (47 of 95). Hospital payer mix was associated with ALL induction mortality after adjustment for other hospital-level factors (P = 0.046). CONCLUSIONS: The overall risk of induction death is low but substantially increased in patients with cardio-respiratory and other organ failures. Induction mortality varies up to three-fold across hospitals and is correlated with hospital payer mix. Further work is needed to improve induction outcomes in hospitals with higher mortality. These data suggest an induction mortality rate of less than 1% may be an attainable national benchmark.

Scheduled surgery admissions and occupancy at a children's hospital: variation we can control to improve efficiency and value in health care delivery.

OBJECTIVE: Describe variability in admission, discharge, and occupancy patterns for surgical patients at a large children's hospital and assess the relationship between scheduled admissions and occupancy. BACKGROUND: High hospital occupancy degrades quality of care and access, whereas low levels of occupancy use hospital resources inefficiently. Variability in scheduling patients for surgical procedures may affect occupancy and be amenable to alteration. METHODS: This is a retrospective administrative data analysis that took place at 1 urban, tertiary-care children's hospital. A total of 8552 surgical patients hospitalized from July 1, 2009, to June 30, 2010, were included in the analysis, and admission-discharge-transfer data for 1 fiscal year were abstracted for analysis of admission and occupancy patterns. RESULTS: Among 6257 surgical admissions for non-intensive care unit (ICU) patients, 49% were emergent and 51% were scheduled. Variation in admission volume by day of week was more than 3 times higher for scheduled admissions than for emergent admissions. For non-ICU surgical patients with length of stay 7 days or less (97%), Mondays and Tuesdays generated 42% of scheduled patient occupancy time. Thursdays and Fridays often had high occupancy of surgical patients (>90% of designated beds filled), whereas Saturdays, Sundays, and Mondays were often at low occupancy for those beds (<80% filled). Only 20% of all days in the year had designated non-ICU surgery beds with occupancy between 80% and 95%. CONCLUSIONS: Scheduled admissions contribute significantly to variability in occupancy. Predictable patterns of admissions lead to high occupancy on some days and unused capacity on others, with few days being at an optimal level of occupancy. These predictable patterns suggest opportunities to improve hospital operations with changes in scheduled admission patterns, which present a different problem than random demand.

Children's hospitals with shorter lengths of stay do not have higher readmission rates.

OBJECTIVE: To test the hypothesis that children's hospitals with shorter length of stay (LOS) for hospitalized patients have higher all-cause readmission rates. STUDY DESIGN: Longitudinal, retrospective cohort study of the Pediatric Health Information System of 183616 admissions within 43 US children's hospitals for appendectomy, asthma, gastroenteritis, and seizure between July 2009 and June 2011. Admissions were stratified by medical complexity, based on whether patients had a complex chronic health condition, were neurologically impaired, or were assisted with medical technology. Outcome measures include LOS; all-cause readmission rates within 3, 7, 15, and 30 days; and the association between hospital-specific mean LOS and all-cause readmission rates as determined by linear regression. RESULTS: Mean LOS was <3 days for all patients across all conditions, except for appendectomy in complex patients (mean LOS 3.7 days, 95% CI 3.47-4.01). Condition-specific 3-, 7-, 15-, and 30-day all-cause readmission rates for noncomplex patients were all <5%. Condition-specific readmission rates for complex patients ranged from <1% at 3 days for seizures to 16% at 30 days for gastroenteritis. There was no linear association between hospital-specific, condition-specific mean LOS, stratified by medical complexity, and all-cause readmission rates at any time interval within 30 days (all P values ≥.10). CONCLUSION: In children's hospitals, LOS is short and readmission rates are low for asthma, appendectomy, gastroenteritis, and seizure admissions. In the conditions studied, there is no association between shorter hospital-specific LOS and higher readmission rates within the LOS observed.

Effects of an education and training intervention on caregiver knowledge of nonurgent pediatric complaints and on child health services utilization.

OBJECTIVES: The objective of this study was to test the impact of an education and training intervention about management of common childhood illnesses on caregiver knowledge and health service use by an index child. METHODS: This was a quasi-experimental, preintervention-postintervention pilot study of a primary care-based intervention among 32 caregivers of urban children aged 7 months to 5 years. Intervention consisted of a 90-minute educational activity developed after input from focus groups and taught by pediatric nurses; it addressed management of fever, colds, and minor trauma in children at home. Caregiver knowledge before, immediately after, and 6 months after intervention was tested using a written instrument. Health services utilization for an index child in the family was collected 6 months before and after intervention. RESULTS: Caregiver knowledge, as assessed by mean score on the test instrument, increased immediately after the intervention. It was lower at 6-month follow-up but remained higher than pretest. Total health services utilization, adjusted for patient and caregiver factors, did not change significantly 6 months after the intervention. After-hours calls to the primary care physician increased from a mean of 0.33 to 1.46 per patient (P = 0.047), making it the only behavior with significant change. Preintervention health services utilization was the strongest positive predictor of postintervention health services use. CONCLUSIONS: The primary care-based intervention led to increased caregiver knowledge regarding management of common minor childhood illnesses and to increased after-hours telephone use. There was no significant decrease in ED use. To reduce reliance on the ED for nonurgent conditions, additional strategies may be needed.

A qualitative assessment of reasons for nonurgent visits to the emergency department: parent and health professional opinions.

OBJECTIVE: Each day, children incur more than 69,000 emergency department (ED) visits, with 58% to 82% of them for nonurgent reasons. The objectives of this study were to elicit and to describe guardians' and health professionals' opinions on reasons for nonurgent pediatric ED visits. METHODS: Focus groups sessions were held with 3 groups of guardians, 2 groups of primary care practitioners, and 1 group of pediatric emergency medicine physicians. Participants identified unique factors and their importance related to nonurgent ED use. RESULTS: A total of 25 guardians and 42 health professionals participated. Guardians had at least 1 child younger than 5 years, most were self-identified racial/ethnic minorities, and nearly all had taken a child to an ED. Guardians focused on perceived illness severity in their children and needs for diagnostic testing or other interventions, as well as accessibility and availability at times of day that worked for them. Professionals focused on systems issues concerning availability of appointments, as well as parents' lack of knowledge of medical conditions and sense of when use of the ED was appropriate. CONCLUSIONS: Guardians' concerns about perceptions of severity of illness in children and their schedules must be considered to effectively reduce nonurgent ED use, which may differ from the perceptions of professionals. Health professionals and systems seeking ways to decrease ED utilization may be able to better match capacity to demand both by increasing accessibility to primary care and by working to overcome guardians' perceptions that only EDs can handle acute illnesses or injuries.

Inpatient capacity at children's hospitals during pandemic (H1N1) 2009 outbreak, United States.

Quantifying how close hospitals came to exhausting capacity during the outbreak of pandemic influenza A (H1N1) 2009 can help the health care system plan for more virulent pandemics. This ecologic analysis used emergency department (ED) and inpatient data from 34 US children's hospitals. For the 11-week pandemic (H1N1) 2009 period during fall 2009, inpatient occupancy reached 95%, which was lower than the 101% occupancy during the 2008-09 seasonal influenza period. Fewer than 1 additional admission per 10 inpatient beds would have caused hospitals to reach 100% occupancy. Using parameters based on historical precedent, we built 5 models projecting inpatient occupancy, varying the ED visit numbers and admission rate for influenza-related ED visits. The 5 scenarios projected median occupancy as high as 132% of capacity. The pandemic did not exhaust inpatient bed capacity, but a more virulent pandemic has the potential to push children's hospitals past their maximum inpatient capacity.

Hospital-based pandemic influenza preparedness and response: strategies to increase surge capacity.

UNLABELLED: In the spring of 2009, the first patients infected with 2009 H1N1 virus were arriving for care in hospitals in the United States. Anticipating a second wave of infection, our hospital leaders initiated multidisciplinary planning activities to prepare to increase capacity by expansion of emergency department (ED) and inpatient functional space and redeployment of medical personnel. EXPERIENCE: During the fall pandemic surge, this urban, tertiary-care children's hospital experienced a 48% increase in ED visits and a 12% increase in daily peak inpatient census. However, several strategies were effective in mitigating the pandemic's impact including using a portion of the hospital's lobby for ED waiting, using a subspecialty clinic and a 24-hour short stay unit to care for ED patients, and using physicians not board certified in pediatric emergency medicine and inpatient-unit medical nurses to care for ED patients. The average time patients waited to be seen by an ED physician and the proportion of children leaving the ED without being seen by a physician was less than for the period when seasonal influenza peaked in the winter of 2008-2009. Furthermore, the ED did not go on divert status, no elective medical or surgical admissions required cancellation, and there were no increases in serious patient safety events. SUMMARY: Our health center successfully met the challenges posed by the 2009 H1N1 outbreak. The intent in sharing the details of our planning and experience is to allow others to determine which elements of this planning might be adapted for managing a surge of patients in their setting.

Hospital-level compliance with asthma care quality measures at children's hospitals and subsequent asthma-related outcomes.

CONTEXT: The Children's Asthma Care (CAC) measure set evaluates whether children admitted to hospitals with asthma receive relievers (CAC-1) and systemic corticosteroids (CAC-2) and whether they are discharged with a home management plan of care (CAC-3). It is the only Joint Commission core measure applicable to evaluate the quality of care for hospitalized children. OBJECTIVES: To evaluate longitudinal trends in CAC measure compliance and to determine if an association exists between compliance and outcomes. DESIGN, SETTING, AND PATIENTS: Cross-sectional study using administrative data and CAC compliance data for 30 US children's hospitals. A total of 37,267 children admitted with asthma between January 1, 2008, and September 30, 2010, with follow-up through December 31, 2010, accounted for 45,499 hospital admissions. Hospital-level CAC measure compliance data were obtained from the National Association of Children's Hospitals and Related Institutions. Readmission and postdischarge emergency department (ED) utilization data were obtained from the Pediatric Health Information System. MAIN OUTCOME MEASURES: Children's Asthma Care measure compliance trends; postdischarge ED utilization and asthma-related readmission rates at 7, 30, and 90 days. RESULTS: The minimum quarterly CAC-1 and CAC-2 measure compliance rates reported by any hospital were 97.1% and 89.5%, respectively. Individual hospital CAC-2 compliance exceeded 95% for 97.9% of the quarters. Lack of variability in CAC-1 and CAC-2 compliance precluded examination of their association with the specified outcomes. Mean CAC-3 compliance was 40.6% (95% CI, 34.1%-47.1%) and 72.9% (95% CI, 68.8%-76.9%) for the initial and final 3 quarters of the study, respectively. The mean 7-, 30-, and 90-day postdischarge ED utilization rates were 1.5% (95% CI, 1.3%-1.6%), 4.3% (95% CI, 4.0%-4.5%), and 11.1% (95% CI, 10.5%-11.7%) and the mean quarterly 7-, 30-, and 90-day readmission rates were 1.4% (95% CI, 1.2%-1.6%), 3.1% (95% CI, 2.8%-3.3%), and 7.6% (95% CI, 7.2%-8.1%). There was no significant association between overall CAC-3 compliance (odds ratio [OR] for 5% improvement in compliance) and postdischarge ED utilization rates at 7 days (OR, 1.00; 95% CI, 0.98-1.02), 30 days (OR, 0.97; 95% CI, 0.90-1.04), and 90 days (OR, 0.96; 95% CI, 0.77-1.18). In addition, there was no significant association between overall CAC-3 compliance (OR for 5% improvement in compliance) and readmission rates at 7 days (OR, 1.00; 95% CI, 0.99-1.02), 30 days (OR, 0.99; 95% CI, 0.96-1.02), and 90 days (OR, 1.01; 95% CI, 0.90-1.12). CONCLUSION: Among children admitted to pediatric hospitals for asthma, there was high hospital-level compliance with CAC-1 and CAC-2 quality measures and moderate compliance with the CAC-3 measure but no association between CAC-3 compliance and subsequent ED visits and asthma-related readmissions.

Observation Encounters and Length of Stay Benchmarking in Children's Hospitals.

BACKGROUND AND OBJECTIVES: Length of stay (LOS) is a common benchmarking measure for hospital resource use and quality. Observation status (OBS) is considered an outpatient service despite the use of the same facilities as inpatient status (IP) in most children's hospitals, and LOS calculations often exclude OBS stays. Variability in the use of OBS by hospitals may significantly impact calculated LOS. We sought to determine the impact of including OBS in calculating LOS across children's hospitals. METHODS: Retrospective cohort study of hospitalized children (age <19 years) in 2017 from the Pediatric Health Information System (Children's Hospital Association, Lenexa, KS). Normal newborns, transfers, deaths, and hospitals not reporting LOS in hours were excluded. Risk-adjusted geometric mean length of stay (RA-LOS) for IP-only and IP plus OBS was calculated and each hospital was ranked by quintile. RESULTS: In 2017, 45 hospitals and 625 032 hospitalizations met inclusion criteria (IP = 410 731 [65.7%], OBS = 214 301 [34.3%]). Across hospitals, OBS represented 0.0% to 60.3% of total discharges. The RA-LOS (SD) in hours for IP and IP plus OBS was 75.2 (2.6) and 54.3 (2.7), respectively (P < .001). For hospitals reporting OBS, the addition of OBS to IP RA-LOS calculations resulted in a decrease in RA-LOS compared with IP encounters alone. Three-fourths of hospitals changed ≥1 quintile in LOS ranking with the inclusion of OBS. CONCLUSIONS: Children's hospitals exhibit significant variability in the assignment of OBS to hospitalized patients and inclusion of OBS significantly impacts RA-LOS calculations. Careful consideration should be given to the inclusion of OBS when determining RA-LOS for benchmarking, quality and resource use measurements.

Room Costs for Common Pediatric Hospitalizations and Cost-Reducing Quality Initiatives.

BACKGROUND: Improvement initiatives promote safe and efficient care for hospitalized children. However, these may be associated with limited cost savings. In this article, we sought to understand the potential financial benefit yielded by improvement initiatives by describing the inpatient allocation of costs for common pediatric diagnoses. METHODS: This study is a retrospective cross-sectional analysis of pediatric patients aged 0 to 21 years from 48 children's hospitals included in the Pediatric Health Information System database from January 1, 2017, to December 31, 2017. We included hospitalizations for 8 common inpatient pediatric diagnoses (seizure, bronchiolitis, asthma, pneumonia, acute gastroenteritis, upper respiratory tract infection, other gastrointestinal diagnoses, and skin and soft tissue infection) and categorized the distribution of hospitalization costs (room, clinical, laboratory, imaging, pharmacy, supplies, and other). We summarized our findings with mean percentages and percent of total costs and used mixed-effects models to account for disease severity and to describe hospital-level variation. RESULTS: For 195 436 hospitalizations, room costs accounted for 52.5% to 70.3% of total hospitalization costs. We observed wide hospital-level variation in nonroom costs for the same diagnoses (25%-81% for seizure, 12%-51% for bronchiolitis, 19%-63% for asthma, 19%-62% for pneumonia, 21%-78% for acute gastroenteritis, 21%-63% for upper respiratory tract infection, 28%-69% for other gastrointestinal diagnoses, and 21%-71% for skin and soft tissue infection). However, to achieve a cost reduction equal to 10% of room costs, large, often unattainable reductions (>100%) in nonroom cost categories are needed. CONCLUSIONS: Inconsistencies in nonroom costs for similar diagnoses suggest hospital-level treatment variation and improvement opportunities. However, individual improvement initiatives may not result in significant cost savings without specifically addressing room costs.

Disparities in Outcomes and Resource Use After Hospitalization for Cardiac Surgery by Neighborhood Income.

BACKGROUND: Significant disparities exist between patients of different races and with different family incomes; less is understood regarding community-level factors on outcomes. METHODS: In this study, we used linked data from the Pediatric Health Information System database and the US Census Bureau to examine associations between median annual household income by zip code and mortality, length of stay, inpatient standardized costs, and costs per day, over and above the effects of race and payer, first for children undergoing cardiac surgery (2005-2015) and then for all pediatric discharges (2012-2015). Median community-level income was examined as continuous and categorical (by quartile) predictors. Hierarchical logistic and censored linear regression models were constructed. To these models, patient and surgical characteristics, year, race, payer, state, urban or rural designation, and center fixed effects were added. RESULTS: We identified 101 013 cardiac surgical (and 857 833 total) hospitalizations from 46 institutions. Children from the lowest-income neighborhoods who were undergoing cardiac surgery had 1.18 times the odds of mortality (95% confidence interval [CI]: 1.03 to 1.35), 7% longer lengths of stay (CI: 1% to 14%), and 7% higher standardized costs (CI: 1% to 14%) than children from the highest-income neighborhoods. Results for all children were similar, both with and without any major chronic conditions. The effects of neighborhood were only partially explained by differences in race, payer, or the centers at which patients received care. There were no differences in costs per day. CONCLUSIONS: Children from lower-income neighborhoods are at increased risk of mortality and use more resource intensive care than children from higher-income communities, even after accounting for disparities between races, payers, and centers.

Using Length of Stay to Understand Patient Flow for Pediatric Inpatients.

OBJECTIVES: Develop and test a new metric to assess meaningful variability in inpatient flow. METHODS: Using the pediatric administrative dataset, Pediatric Health Information System, that quantifies the length of stay (LOS) in hours, all inpatient and observation encounters with 21 common diagnoses were included from the calendar year 2013 in 38 pediatric hospitals. Two mutually exclusive composite groups based on diagnosis and presence or absence of an ICU hospitalization termed Acute Care Composite (ACC) and ICU Composite (ICUC), respectively, were created. These composites consisted of an observed-to-expected (O/E) LOS as well as an excess LOS percentage (ie, the percent of day beyond expected). Seven-day all-cause risk-adjusted rehospitalizations was used as a balancing measure. The combination of the ACC, the ICUC, and the rehospitalization measures forms this new metric. RESULTS: The diagnosis groups in the ACC and the ICUC included 113,768 and 38,400 hospitalizations, respectively. The ACC had a median O/E LOS of 1.0, a median excess LOS percentage of 23.9% and a rehospitalization rate of 1.7%. The ICUC had a median O/E LOS of 1.1, a median excess LOS percentage of 32.3%, and rehospitalization rate of 4.9%. There was no relationship of O/E LOS and rehospitalization for either ACC or ICUC. CONCLUSIONS: This metric shows variation among hospitals and could allow a pediatric hospital to assess the performance of inpatient flow.

Hypothetical Network Adequacy Schemes For Children Fail To Ensure Patients' Access To In-Network Children's Hospital.

Insurers are increasingly adopting narrow network strategies. Little is known about how these strategies may affect children's access to needed specialty care. We examined the percentage of pediatric specialty hospitalizations that would be beyond existing Medicare Advantage network adequacy distance requirements for adult hospital care and, as a secondary analysis, a pediatric adaptation of the Medicare Advantage requirements. We examined 748,920 hospitalizations at eighty-one children's hospitals that submitted data for the period October 2014-September 2015. Nearly half of specialty hospitalizations were outside the Medicare Advantage distance requirements. Under the pediatric adaptation, there was great variability among the hospitals, with the percent of hospitalizations beyond the distance requirements ranging from less than 1 percent to 35 percent. Instead of, or in addition to, time and distance standards, policy makers may need to consider more nuanced network definitions, including functional capabilities of the pediatric care network or clear exception policies for essential specialty care services.

Financial Analysis of an Intensive Pediatric Continuous Positive Airway Pressure Program.

Study Objectives: Continuous positive airway pressure (CPAP) is effective in treating obstructive sleep apnea in children, but adherence to therapy is low. Our center created an intensive program that aimed to improve adherence. Our objective was to estimate the program's efficacy, cost, revenue and break-even point in a generalizable manner relative to a standard approach. Methods: The intensive program included device consignment, behavioral psychology counseling, and follow-up telephone calls. Economic modeling considered the costs, revenue and break-even point. Costs were derived from national salary reports and the Pediatric Health Information System. The 2015 Medicare reimbursement schedule provided revenue estimates. Results: Prior to the intensive CPAP program, only 67.6% of 244 patients initially prescribed CPAP appeared for follow-up visits and only 38.1% had titration polysomnograms. In contrast, 81.4% of 275 patients in the intensive program appeared for follow-up visits (p < .001) and 83.6% had titration polysomnograms (p < .001). Medicare reimbursement levels would be insufficient to cover the estimated costs of the intensive program; break-even points would need to be 1.29-2.08 times higher to cover the costs. Conclusions: An intensive CPAP program leads to substantially higher follow-up and CPAP titration rates, but costs are higher. While affordable at our institution due to the local payer mix and revenue, Medicare reimbursement levels would not cover estimated costs. This study highlights the need for enhanced funding for pediatric CPAP programs, due to the special needs of this population and the long-term health risks of suboptimally treated obstructive sleep apnea.

Regional Variation in Standardized Costs of Care at Children's Hospitals.

OBJECTIVE: (1) To evaluate regional variation in costs of care for 3 inpatient pediatric conditions, (2) assess potential drivers of variation, and (3) estimate cost savings from reducing variation. DESIGN/SETTING: Retrospective cohort study of hospitalizations for asthma, diabetic ketoacidosis (DKA), and acute gastroenteritis (AGE) at 46 children

Children's Hospital Characteristics and Readmission Metrics.

BACKGROUND AND OBJECTIVE: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves. METHODS: We performed a cross-sectional analysis of 64 children's hospitals from the Children's Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression. RESULTS: We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%-19.6%); the mean PPR rate was 4.9% (range 2.9%-6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63-1.23), compared with 0.95 (range 0.65-1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR. CONCLUSIONS: High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.