A National Survey of Pediatric Post-Acute Care Facilities.

OBJECTIVES: To identify and geolocate pediatric post-acute care (PAC) facilities in the United States. DESIGN: Cross-sectional survey using both online resources and telephone inquiry. SETTING: All 50 U.S. states surveyed from June 2022 to May 2023. Care sites identified via state regulatory agencies and the Centers for Medicare & Medicaid Services. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Number, size, and type of facility, scope of practice, and type of care provided. One thousand three hundred fifty-five facilities were surveyed; of these, 18.6% (252/1355) were pediatric-specific units or adult facilities accepting some pediatric patients. There were 109 pediatric-specific facilities identified within 39 U.S. states. Of these, 38 were freestanding with all accepting children with tracheostomies, 97.4% (37/38) accepting those requiring mechanical ventilation via tracheostomy, and 81.6% (31/38) accepting those requiring parenteral nutrition. The remaining 71 facilities were adult facilities with embedded pediatric units or children's hospitals with 88.7% (63/71), 54.9% (39/71), and 54.9% (39/71), accepting tracheostomies, mechanical ventilation via tracheostomy, and parenteral nutrition, respectively. Eleven states lacked any pediatric-specific PAC units or facilities. CONCLUSIONS: The distribution of pediatric PAC is sparse and uneven across the United States. We present an interactive map and database describing these facilities. These data offer a starting point for exploring the consequences of pediatric PAC supply.

Impact of Allocation on Survival During Intermittent Chemotherapy Shortages: A Modeling Analysis.

BACKGROUND: Intermittent shortages of chemotherapeutics used to treat curable malignancies are a worldwide problem that increases patient mortality. Although multiple strategies have been proposed for managing these shortages (eg, prioritizing patients by age, scarce treatment efficacy per volume, alternative treatment efficacy difference), critical clinical dilemmas arise when selecting a management strategy and understanding its impact. PATIENTS AND METHODS: We developed a model to compare the impact of different allocation strategies on overall survival during intermittent chemotherapy shortages and tested it using vincristine, which was recently scarce for 9 months in the United States. Demographic and treatment data were abstracted from 1,689 previously treated patients in our tertiary-care system; alternatives were abstracted from NCCN Clinical Practice Guidelines in Oncology for each disease and survival probabilities from the studies cited therein. Modeled survival was validated using SEER data. Nine-month shortages were modeled for all possible supply levels. Pairwise differences in 3-year survival and risk reductions were calculated for each strategy compared with standard practice (first-come, first-served) for each 50-mg supply increment, as were supply thresholds above which each strategy maintained survival similar to scenarios without shortages. RESULTS: A strategy prioritizing by higher vincristine efficacy per volume and greater alternative treatment efficacy difference performed best, improving survival significantly (P<.01) across 86.5% of possible shortages (relative risk reduction, 8.3%; 99% CI, 8.0-8.5) compared with standard practice. This strategy also maintained survival rates similar to a model without shortages until supply fell below 72.2% of the amount required to treat all patients, compared with 94.3% for standard practice. CONCLUSIONS: During modeled vincristine shortages, prioritizing patients by higher efficacy per volume and alternative treatment efficacy difference significantly improved survival over standard practice. This approach can help optimize allocation as intermittent chemotherapy shortages continue to arise.

Supraventricular Tachycardia in Infants With Congenital Diaphragmatic Hernia: Prevalence, Associations, and Outcomes.

OBJECTIVES: To characterize the prevalence, associations, management, and outcomes of supraventricular tachycardia (SVT) in neonates with congenital diaphragmatic hernia (CDH). DESIGN: Retrospective chart and cardiology code review within a cohort of patients with CDH was used to define a subpopulation with atrial arrhythmia. SVT mechanisms were confirmed by electrocardiogram analysis. Cox proportional hazard regression identified risk factors for SVT and association with clinical outcomes. SETTING: Medical Surgical ICU in a single, tertiary center, Boston Children's Hospital. PATIENTS: Eligible patients included neonates presenting with classic Bochdalek posterolateral CDH between 2005 and 2017, excluding newborns with Morgagni hernia or late diagnoses of CDH (>28 d). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: SVT arose in 25 of 232 neonates with CDH, (11%); 14 of 25 infants (56%) had recurrent SVT; atrioventricular node-dependent tachycardia was the most frequent mechanism (32%). The majority (71%) of SVT episodes received intervention. Nine patients (36%) received preventative antiarrhythmic medications. SVT was associated with lower Apgar score at 1 min, structural heart disease, larger defect size, extracorporeal membrane oxygenation (ECMO) support, and prostaglandin therapy for ductal patency as well as hospital stay greater than or equal to 8 weeks and use of supplemental oxygen at discharge. CONCLUSIONS: SVT can occur in neonates with CDH and frequently requires treatment. Odds of occurrence are increased with greater CDH disease severity, ECMO, and prostaglandin use. In unadjusted logistic regression analysis, SVT was associated with adverse hospital outcomes, underscoring the importance of recognition and management in this vulnerable population.

Availability of Inpatient Pediatric Surgery in the United States.

BACKGROUND: In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery. METHODS: A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth. RESULTS: Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation. CONCLUSIONS: Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

Socioeconomic Disadvantage and Distance to Pediatric Critical Care.

OBJECTIVES: To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States. DESIGN: Retrospective, cross-sectional study. SETTING: Contiguous United States. PATIENTS: Children less than 18 years as represented in the 2016 American Community Survey. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas. CONCLUSIONS: In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models.

OBJECTIVE: To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. DESIGN: All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. SETTING: Tertiary children's hospital. SUBJECTS: Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. CONCLUSIONS: Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

The nature and sources of variability in pediatric surgical case duration.

BACKGROUND: Case time variability confounds surgical scheduling and decreases access to limited operating room resources. Variability arises from many sources and can differ among institutions serving different populations. A rich literature has developed around case time variability in adults, but little in pediatrics. OBJECTIVE: We studied the effect of commonly used patient and procedure factors in driving case time variability in a large, free-standing, academic pediatric hospital. METHODS: We analyzed over 40 000 scheduled surgeries performed over 3 years. Using bootstrapping, we computed descriptive statistics for 249 procedures and reported variability statistics. We then used conditional inference regression trees to identify procedure and patient factors associated with pediatric case time and evaluated their predictive power by comparing prediction errors against current practice. Patient and procedure factors included patient's age and weight, medical status, surgeon identity, and ICU request indicator. RESULTS: Overall variability in pediatric case time, as reflected by standard deviation, was 30% (25.8, 34.7) of the median case time. Relative variability (coefficient of variation), was largest among short cases. For a few procedure types, the regression tree can improve prediction accuracy if extreme behavior cases are preemptively identified. However, for most procedure types, no useful predictive factors were identified and, most notably, surgeon identity was unimportant. CONCLUSIONS: Pediatric case time variability, unlike adult cases, is poorly explained by surgeon effect or other characteristics that are commonly abstracted from electronic records. This largely relates to the 'long-tailed' distribution of pediatric cases and unpredictably long cases. Surgeon-specific scheduling is therefore unnecessary and similar cases may be pooled across surgeons. Future scheduling efforts in pediatrics should focus on prospective identification of patient and procedural specifics that are associated with and predictive of long cases. Until such predictors are identified, daily management of pediatric operating rooms will require compensatory overtime, capacity buffers, schedule flexibility, and cost.

Pediatric Respiratory Syncytial Virus Hospitalizations and Respiratory Support After the COVID-19 Pandemic.

Importance: After the COVID-19 pandemic, there was a surge of pediatric respiratory syncytial virus (RSV) infections, but national data on hospitalization and intensive care unit use and advanced respiratory support modalities have not been reported. Objective: To analyze demographics, respiratory support modes, and clinical outcomes of children with RSV infections at tertiary pediatric hospitals from 2017 to 2023. Design, Setting, and Participants: This cross-sectional study evaluated children from 48 freestanding US children's hospitals registered in the Pediatric Health Information System (PHIS) database. Patients 5 years or younger with RSV from July 1, 2017, to June 30, 2023, were included. Each season was defined from July 1 to June 30. Prepandemic RSV seasons included 2017 to 2018, 2018 to 2019, and 2019 to 2020. The postpandemic season was delineated as 2022 to 2023. Exposure: Hospital presentation with RSV infection. Main Outcomes and Measures: Data on emergency department presentations, hospital or intensive care unit admission and length of stay, demographics, respiratory support use, mortality, and cardiopulmonary resuscitation were analyzed. Postpandemic season data were compared with prepandemic seasonal averages. Results: A total of 288 816 children aged 5 years or younger (median [IQR] age, 8.9 [3.3-21.5] months; 159 348 [55.2%] male) presented to 48 US children's hospitals with RSV from July 1, 2017, to June 30, 2023. Respiratory syncytial virus hospital presentations increased from 39 698 before the COVID-19 pandemic to 94 347 after the pandemic (P < .001), with 86.7% more hospitalizations than before the pandemic (50 619 vs 27 114; P < .001). In 2022 to 2023, children were older (median [IQR] age, 11.3 [4.1-26.6] months vs 6.8 [2.6-16.8] months; P < .001) and had fewer comorbidities (17.6% vs 21.8% of hospitalized patients; P < .001) than during prepandemic seasons. Advanced respiratory support use increased 70.1% in 2022 to 2023 (9094 vs 5340; P < .001), and children requiring high-flow nasal cannula (HFNC) or noninvasive ventilation (NIV) were older than during prepandemic seasons (median [IQR] age for HFNC, 6.9 [2.7-16.0] months vs 4.6 [2.0-11.7] months; for NIV, 6.0 [2.1-16.5] months vs 4.3 [1.9-11.9] months). Comorbid conditions were less frequent after the pandemic across all respiratory support modalities (HFNC, 14.9% vs 19.1%, NIV, 22.0% vs 28.5%, invasive mechanical ventilation, 30.5% vs 38.0%; P < .001). Conclusions and Relevance: This cross-sectional study identified a postpandemic pediatric RSV surge that resulted in markedly increased hospital volumes and advanced respiratory support needs in older children with fewer comorbidities than prepandemic seasons. These clinical trends may inform novel vaccine allocation to reduce the overall burden during future RSV seasons.

Neighborhood Poverty and Distance to Pediatric Hospital Care.

OBJECTIVE: To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care. METHODS: This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity. RESULTS: Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001). CONCLUSIONS: Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.

Hospital Access Patterns of Children With Technology Dependence.

OBJECTIVES: We studied hospital utilization patterns among children with technology dependence (CTD). We hypothesized that increasing pediatric healthcare concentration requires those caring for CTD to selectively navigate healthcare systems and travel greater distances for care. METHODS: Using 2017 all-encounter datasets from 6 US states, we identified CTD visits defined by presence of a tracheostomy, gastrostomy, or intraventricular shunt. We calculated pediatric Hospital Capability Indices for hospitals and mapped distances between patient residence, nearest hospital, and encounter facility. RESULTS: Thirty-five percent of hospitals never saw CTD. Of 37 108 CTD encounters within the remaining 543 hospitals, most emergency visits (70.0%) and inpatient admissions (85.3%) occurred within 34 (6.3%) high capability centers. Only 11.7% of visits were to the closest facility, as CTD traveled almost 4 times further to receive care. When CTD bypassed nearer facilities, they were 10 times more likely to travel to high-capability centers (95% confidence interval: 9.43-10.8), but even those accessing low-capability facilities bypassed less capable, geographically closer hospitals. Transfer was more likely in nearest and low-capability facility encounters. CTD with Medicaid insurance, Black race, or from lower socioeconomic communities had lower odds of encounters at high-capability centers and of bypassing a closer institution than those with white race, private insurance, or from advantaged communities. CONCLUSIONS: Children with technology dependence routinely bypass closer hospitals to access care in facilities with higher pediatric capability. This access behavior leaves many hospitals unfamiliar with CTD, which results in greater travel but less transfers and may be influenced by sociodemographic factors.

Patterns in hospital admissions for adults with congenital heart disease for non-cardiac procedures.

OBJECTIVE: Advances in management of congenital heart disease (CHD) have led to an increasing population of adults with CHD, many of whom require non-cardiac procedures. The objectives of this study were to describe the characteristics of these patients, their distribution among different hospital categories and the characteristics determining this distribution, and mortality rates following noncardiac procedures. METHODS: We retrospectively analysed 27 state inpatient databases. Encounters with CHD and non-cardiac procedures were included. The location of care was classified into two categories: hospitals with and without cardiac surgical programmes. Variables included were demographics, comorbidity index, mortality. Multivariable logistic regression was used to explore predictors for care in different locations. RESULTS: The cohort consisted of 12 944 encounters in 1206 hospitals. Most patients were cared for in hospitals with a cardiac surgical programme (78.1%). Patients presenting to hospitals with a cardiac surgical programme presented with higher comorbidity index (6 (IQR: 0-19) vs 2 (IQR: -3-14), p<0.001) than patients presenting to hospitals without a cardiac surgical programme. Mortality was higher in hospitals with cardiac surgical programmes compared with hospitals without cardiac surgical programmes (4.0% vs 2.3%, p<0.001). Factors associated with provision of care at a hospital with a cardiac surgical programme were comorbidity index (>7: OR 2.01 (95% CI 1.83 to 2.21), p<0.001; 2-7: OR 1.59 (95% CI 1.41 to 1.79), p<0.001) and age (18-44 years: OR 1.43 (95% CI 1.26 to 1.62), p<0.001; 45-64 years: OR 1.21 (95% CI 1.08 to 1.34), p<0.001). CONCLUSION: Adults with CHD undergoing non-cardiac procedures are mainly cared for in hospitals with a cardiac surgical programme and have greater comorbidities and higher mortality than those in centres without cardiac surgical programmes. Risk stratification and locoregional accessibility need further assessment to fully understand admission patterns.

GM-CSF provides autocrine protection for murine alveolar epithelial cells from oxidant-induced mitochondrial injury.

Exposure of mice to hyperoxia induces alveolar epithelial cell (AEC) injury, acute lung injury and death. Overexpression of granulocyte-macrophage colony-stimulating factor (GM-CSF) in the lung protects against these effects, although the mechanisms are not yet clear. Hyperoxia induces cellular injury via effects on mitochondrial integrity, associated with induction of proapoptotic members of the Bcl-2 family. We hypothesized that GM-CSF protects AEC through effects on mitochondrial integrity. MLE-12 cells (a murine type II cell line) and primary murine type II AEC were subjected to oxidative stress by exposure to 80% oxygen and by exposure to H(2)O(2). Exposure to H(2)O(2) induced cytochrome c release and decreased mitochondrial reductase activity in MLE-12 cells. Incubation with GM-CSF significantly attenuated these effects. Protection induced by GM-CSF was associated with Akt activation. GM-CSF treatment also resulted in increased expression of the antiapoptotic Bcl-2 family member, Mcl-1. Primary murine AEC were significantly more tolerant of oxidative stress than MLE-12 cells. In contrast to MLE-12 cells, primary AEC expressed significant GM-CSF at baseline and demonstrated constitutive activation of Akt and increased baseline expression of Mcl-1. Treatment with exogenous GM-CSF further increased Akt activation and Mcl-1 expression in primary AEC. Conversely, suppression of AEC GM-CSF expression by use of GM-CSF-specific small interfering RNA resulted in decreased tolerance of oxidative stress, Furthermore, silencing of Mcl-1 prevented GM-CSF-induced protection. We conclude that GM-CSF protects alveolar epithelial cells against oxidative stress-induced mitochondrial injury via the Akt pathway and its downstream components, including Mcl-1. Epithelial cell-derived GM-CSF may contribute to intrinsic defense mechanisms limiting lung injury.

Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma.

OBJECTIVE: To describe the current system of pediatric asthma care and identify potential options for unloading tertiary centers. METHODS: Retrospective, cross-sectional study using 2014 inpatient and emergency department all-encounter administrative datasets from Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. Study participants included children <18 with primary diagnosis of asthma. RESULTS: There were 174,239 encounters for pediatric asthma, with 26,316 admissions and 3101 transfers. About 94.4% of transfers were admitted, with median stay length 2 days (interquartile range [IQR] 1.0-3.0). About 637 hospitals saw pediatric asthma, but 58.7% never admitted these patients. Fifty-four hospitals (8.5%) regularly received transfers; these hospitals were broadly capable pediatric centers (mean pediatric hospital capability indices = 0.82, IQR: 0.64-0.89). Two hundred nine facilities (32.8%) did not regularly receive transfers but were highly capable of caring for pediatric asthma (mean condition-specific capability = 0.92, IQR: 0.85-1.00). Median distance from transferring hospitals to the nearest pediatric center was 25.7 miles (IQR: 6.45-50.15) vs 18.0 miles (IQR: 8.35-29.25) to the nearest potential receiving hospital. Mean cost of a 2-day asthma admission in receiving hospitals was $3927 (IQR: $3083-$4894) versus $3427 (IQR: $2485-$4102) in potential receivers. CONCLUSIONS: While nearly all acute care hospitals encounter children with asthma, more than half never admit them. Children are primarily transferred to a small subset of specialized centers, despite the existence, in many regions, of closer community hospitals with high pediatric asthma capability. In settings with long transfer distances and tertiary center crowding, a tiered system of hospital care for pediatric asthma may be feasible.

Patients With Congenital Heart Disease Undergoing Noncardiac Procedures at Hospitals With and Without a Cardiac Surgical Program.

Background The type and location of hospitals where patients with congenital heart disease (CHD) undergo noncardiac procedures have not been investigated. This study aimed to describe (1) the characteristics of these patients, (2) the distribution of procedures among hospitals with and without a cardiac surgical program and travel distances, (3) the characteristics determining the distribution, and (4) mortality rates. Methods and Results This is a retrospective cohort analysis of inpatient data from the Center for Healthcare Information and Analysis of the Commonwealth of Massachusetts, Texas Healthcare Information Collection, and Health Care Cost and Utilization Project State Inpatient Database. Children <18 years old with CHD who underwent noncardiac procedures were included. Distances were calculated using the Haversine formula. Logistic regression was performed to evaluate the odds of a procedure at a hospital with a cardiac program. There were 7435 encounters at 235 hospitals analyzed. Most procedures (87.8%) occurred at hospitals with a cardiac program. Patients at a hospital without a cardiac program had simple CHD (72.4%) with <1% with single ventricle disease. At hospitals with a cardiac program, 56.8% had simple CHD, 35.4% complex CHD, and 7.8% single ventricle disease. The median distance traveled was 25.2 miles (interquartile range, 10.3-73.8 miles) to a hospital with a cardiac program and 14.6 miles (interquartile range, 6.2-37.4 miles) to a hospital without a cardiac program (P<0.001). Single ventricle disease (adjusted odds ratio [aOR], 16.25 [95% CI, 7.22-36.61]) and ≥6 chronic conditions (aOR, 1.81 [95% CI, 1.57-2.09]) were associated with performance at a hospital with a cardiac program. Mortality rate was 3.8%. Conclusions Patients with CHD are more likely to travel to a hospital with a cardiac program for noncardiac procedures than to a hospital without; especially patients with single ventricle disease, other complex CHD, and with ≥6 chronic conditions.

Host specificity of microsporidia pathogenic to the gypsy moth, Lymantria dispar (L.): field studies in Slovakia.

Several species of microsporidia are important chronic pathogens of Lymantria dispar in Europe but have never been recovered from North American gypsy moth populations. The major issue for their introduction into North American L. dispar populations is concern about their safety to native non-target insects. In this study, we evaluated the susceptibility of sympatric non-target Lepidoptera to two species of microsporidia, Nosema lymantriae and Vairimorpha disparis, isolated from European populations of L. dispar and applied in field plots in Slovakia. Application of ultra low volume sprays of the microsporidia maximized coverage of infective spores in a complex natural environment and, thus, exposure of non-target species to the pathogens. Of 653 non-target larvae collected from plots treated with V. disparis in 2002, 18 individual larvae representing nine species in four families were infected. These plots were monitored for two subsequent seasons and V. disparis was not recovered from non-target species. Of 2571 non-target larvae collected in N. lymantriae-treated sites, one larva was found to be infected. Both species of microsporidia, particularly N. lymantriae, appear to have a very narrow host range in the field, even when an inundative technique is used for their introduction. V. disparis infections in L. dispar exceeded 40% of recovered larvae in the treated study sites; infection rates were lower in sites sprayed with N. lymantriae. Several naturally-occurring pathogens were recorded from the non-target species. The most common pathogen, isolated from 21 species in eight families, was a microsporidium in the genus Cystosporogenes.

Trends in the Use of Noninvasive and Invasive Ventilation for Severe Asthma.

OBJECTIVES: To explore and define contemporary trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in the treatment of children with asthma. METHODS: We performed a serial cross-sectional analysis using data from the Pediatric Health Information System. We examined 2014-2018 admission abstracts from patients aged 2 to 17 years who were admitted to member hospitals with a primary diagnosis of asthma. We report temporal trends in IMV use, NIV use, ICU admission, length of stay, and mortality. RESULTS: Over the study period, 48 hospitals reported 95 204 admissions with a primary diagnosis of asthma. Overall, IMV use remained stable at 0.6% between 2014 and 2018 (interquartile range [IQR]: 0.3%-1.1% and 0.2%-1.3%, respectively), whereas NIV use increased from 1.5% (IQR: 0.3%-3.2%) to 2.1% (IQR: 0.3%-5.6%). There was considerable practice variation among centers, with NIV rates more than doubling within the highest quartile of users (from 4.8% [IQR: 2.8%-7.5%] to 13.2% [IQR: 7.4%-15.2%]; P < .02). ICU admission was more common among centers with high NIV use, but centers with high NIV use did not differ from lower-use centers in mortality, IMV use, or overall average length of stay. CONCLUSIONS: The use of IMV is at historic lows, and NIV has replaced it as the primary mechanical support mode for asthma. However, there is considerable variability in NIV use. Increased NIV use was not associated with a change in IMV rates, which remained stable. Higher NIV use was associated with increased ICU admissions. NIV's precise contribution to the cost and quality of care remains to be determined.

Assessment of Acute Hospital Use and Transfers for Management of Pediatric Seizures.

Importance: The availability of pediatric hospital care for common conditions is decreasing across the US. The consequences of this decrease on access to care for specific conditions need to be evaluated. Objective: To evaluate the degree of regionalization of pediatric seizure care in the US by characterizing the activity of hospital systems in 6 diverse states. Design, Setting, and Participants: This retrospective cross-sectional study used inpatient and emergency department administrative data sets from all acute care hospitals in Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York from 2014. All patients younger than 18 years who visited a hospital and had a primary diagnosis of seizures were included. Data were analyzed between January and June 2019. Main Outcomes and Measures: Characteristics of hospital encounters and pediatric Hospital Capability Index scores of transferring and admitting hospitals. Results: Among 57 930 encounters with pediatric patients with seizures (median [range] age, 4 [1-11] years; 31 968 [55.2%] boys) identified in 621 acute care hospitals, 15 467 patients (26.7%) were admitted as inpatients and 3748 patients (6.5%) were transferred between acute care hospitals. Among encounters that resulted in transfers between hospitals, seizure was the only diagnosis in 1554 patients (41.5%). A total of 42 463 encounters began as emergency department visits, of which 38 173 encounters (90.0%) resulted in routine discharge. While 536 hospitals (86.3%) transferred children with seizures, only 232 hospitals (37.4%) ever admitted them and only 63 hospitals (10.1%) ever received a pediatric seizure transfer. The median (interquartile range) pediatric Hospital Capability Index score of all hospitals was 0.10 (0.02-0.28), while that of hospitals occasionally admitting pediatric seizure patients was 0.34 (0.22-0.55). However, although most patients who were admitted had brief stays (ie, ≤2 days) and no comorbidities, three-quarters of all admissions (12 002 admissions [77.6%]) were to very highly capable centers (ie, hospitals with pediatric Hospital Capability Index scores >0.75). Across all states, the number of referral hospitals for pediatric seizures was less than the number of Dartmouth Atlas Hospital Referral Regions (47 referral hospitals vs 63 hospital referral regions). Conclusions and Relevance: These findings suggest that although children with seizures are seen in almost all acute care hospital emergency departments, most hospitals transfer children who require admission. Condition-specific interhospital dependency challenges standard definitions of network adequacy and should be accounted for in emergency medical service planning, access to care policies, and health services research.

Visualizing Patterns in Pediatric and Adult Hospital Care.

OBJECTIVES: We aimed to design a graphical tool for understanding and effectively communicating the complex differences between pediatric and adult hospital care systems. PATIENTS AND METHODS: We analyzed the most recent hospital administrative data sets for inpatient admission and emergency department visits from 7 US states (2014: Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York; 2011: California). Probabilities of care completion (Pcc) were calculated for pediatric (<18 years old) and adult conditions in all acute-care hospitals in each state. Using the Pcc, we constructed interactive heatmap visualizations for direct comparison of pediatric and adult hospital care systems. RESULTS: On average, across the 7 states, 70.6% of all hospitals had Pcc >0.5 for more than half of all adult conditions, whereas <14.9% of hospitals had Pcc >0.1 for half of pediatric conditions. Visualizations revealed wide variation among states with clearly apparent institutional dependencies and condition-specific gaps (full interactive versions are available at https://goo.gl/5t8vAw). CONCLUSIONS: The functional disparities between pediatric and adult hospital care systems are substantial, and condition-specific differences should be considered in reimbursement strategies, disaster planning, network adequacy determinations, and public health planning.

Quantifying horizontal transmission of Nosema lymantriae, a microsporidian pathogen of the gypsy moth, Lymantria dispar (Lep., Lymantriidae) in field cage studies.

Nosema lymantriae is a microsporidian pathogen of the gypsy moth, Lymantria dispar that has been documented to be at least partially responsible for the collapse of L. dispar outbreak populations in Europe. To quantify horizontal transmission of this pathogen under field conditions we performed caged-tree experiments that varied (1) the density of the pathogen through the introduction of laboratory-infected larvae, and (2) the total time that susceptible (test) larvae were exposed to these infected larvae. The time frame of the experiments extended from the early phase of colonization of the target tissues by the microsporidium to the onset of pathogen-induced mortality or pupation of test larvae. Upon termination of each experiment, the prevalence of infection in test larvae was evaluated. In the experiments performed over a range of pathogen densities, infection of test larvae increased with increasing density of inoculated larvae, from 14.2+/-3.5% at density of 10 inoculated per 100 larvae to 36.7+/-5.7% at 30 inoculated per 100 larvae. At higher densities, percent infection in test larvae appeared to level off (35.7+/-5.5% at 50 inoculated per 100 larvae). When larval exposure to the pathogen was varied, transmission of N. lymantriae did not occur within the first 15 d post-inoculation (dpi) (11 d post-exposure of test larvae to inoculated larvae). We found the first infected test larvae in samples taken 20dpi (16 d post-exposure). Transmission increased over time; in the cages sampled 25dpi (21 d post-exposure), Nosema prevalence in test larvae ranged from 20.6% to 39.2%.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis.

Importance: Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend. Objectives: To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care. Design, Setting, and Participants: Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included. Main Outcomes and Measures: Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals. Results: There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%). Conclusions and Relevance: In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.