Validity of claims-based algorithms to identify neurodevelopmental disorders in children.

PURPOSE: To validate healthcare claim-based algorithms for neurodevelopmental disorders (NDD) in children using medical records as the reference. METHODS: Using a clinical data warehouse of patients receiving outpatient or inpatient care at two hospitals in Boston, we identified children (≤14 years between 2010 and 2014) with at least one of the following NDDs according to claims-based algorithms: autism spectrum disorder/pervasive developmental disorder (ASD), attention deficit disorder/other hyperkinetic syndromes of childhood (ADHD), learning disability, speech/language disorder, developmental coordination disorder (DCD), intellectual disability, and behavioral disorder. Fifty cases per outcome were randomly sampled and their medical records were independently reviewed by two physicians to adjudicate the outcome presence. Positive predictive values (PPVs) and 95% confidence intervals (CIs) were calculated. RESULTS: PPVs were 94% (95% CI, 83%-99%) for ASD, 88% (76%-95%) for ADHD, 98% (89%-100%) for learning disability, 98% (89%-100%) for speech/language disorder, 82% (69%-91%) for intellectual disability, and 92% (81%-98%) for behavioral disorder. A total of 19 of the 50 algorithm-based cases of DCD were confirmed as severe coordination disorders with functional impairment, with a PPV of 38% (25%-53%). Among the 31 false-positive cases of DCD were 7 children with coordination deficits that did not persist throughout childhood, 7 with visual-motor integration deficits, 12 with coordination issues due to an underlying medical condition and 5 with ADHD and at least one other severe NDD. CONCLUSIONS: PPVs were generally high (range: 82%-98%), suggesting that claims-based algorithms can be used to study NDDs. For DCD, additional criteria are needed to improve the classification of true cases.

Extremity fracture pain after emergency department reduction and casting: predictors of pain after discharge.

STUDY OBJECTIVE: The aims of this study are to determine the prevalence of pediatric extremity fracture pain after emergency department (ED) discharge, compare pain severity between fractures requiring simple casting versus sedated reduction and casting, and explore predictors of postdischarge pain. METHODS: This is a prospective observational study of children aged 4 to younger than 18 years and presenting to the ED with extremity fracture from May 2010 to February 2011. The Parents' Postoperative Pain Measure, which scores pain according to 15 behavior-related questions, was completed 48 to 72 hours after discharge. A score greater than or equal to 6 of 15 indicates clinically meaningful pain. Univariate tests and multivariable regression analyses were used to compare Parents' Postoperative Pain Measure scores between cohorts. RESULTS: Two hundred fifty-seven patients were enrolled; 202 (79%) had Parents' Postoperative Pain Measure scores for analysis. Pain scores greater than or equal to 6 were reported by 37 of 102 (36%) of the simple casted and 44 of 100 (44%) of the reduced casted children. There was no difference in scores between the simple (median 4.0) and reduced casted (median 5.0) cohorts (difference 16.7%; 95% confidence interval [CI] -3.0% to 40%). In the multivariate analysis, ED narcotic administration was associated with 24% higher Parents' Postoperative Pain Measure scores (95% CI 0.95% to 53.6%). Children receiving ED narcotics had more than 2 times increased odds of pain scores greater than or equal to 6 after discharge (95% CI 1.24 to 5.39). CONCLUSION: Children in both simple casted and reduced casted groups had clinically meaningful pain after ED discharge. Identifying these children is important to improving pain management and discharge care.