Persistent Opioid Use Following Pediatric Nonfatal Firearm Injury.

OBJECTIVE: Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims. METHODS: We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use. RESULTS: Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use. CONCLUSIONS: Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.

Driving Pressure, Elastance, and Outcomes in a Real-World Setting: A Bi-Center Analysis of Electronic Health Record Data.

Emerging evidence suggests the potential importance of inspiratory driving pressure (DP) and respiratory system elastance (ERS) on outcomes among patients with the acute respiratory distress syndrome. Their association with outcomes among heterogeneous populations outside of a controlled clinical trial is underexplored. We used electronic health record (EHR) data to characterize the associations of DP and ERS with clinical outcomes in a real-world heterogenous population. DESIGN: Observational cohort study. SETTING: Fourteen ICUs in two quaternary academic medical centers. PATIENTS: Adult patients who received mechanical ventilation for more than 48 hours and less than 30 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: EHR data from 4,233 ventilated patients from 2016 to 2018 were extracted, harmonized, and merged. A minority of the analytic cohort (37%) experienced a Pao2/Fio2 of less than 300. A time-weighted mean exposure was calculated for ventilatory variables including tidal volume (VT), plateau pressures (PPLAT), DP, and ERS. Lung-protective ventilation adherence was high (94% with VT < 8.5 mL/kg, time-weighted mean VT = 6. 8 mL/kg, 88% with PPLAT ≤ 30 cm H2O). Although time-weighted mean DP (12.2 cm H2O) and ERS (1.9 cm H2O/[mL/kg]) were modest, 29% and 39% of the cohort experienced a DP greater than 15 cm H2O or an ERS greater than 2 cm H2O/(mL/kg), respectively. Regression modeling with adjustment for relevant covariates determined that exposure to time-weighted mean DP (> 15 cm H2O) was associated with increased adjusted risk of mortality and reduced adjusted ventilator-free days independent of adherence to lung-protective ventilation. Similarly, exposure to time-weighted mean ERS greater than 2 cm H2O/(mL/kg) was associated with increased adjusted risk of mortality. CONCLUSIONS: Elevated DP and ERS are associated with increased risk of mortality among ventilated patients independent of severity of illness or oxygenation impairment. EHR data can enable assessment of time-weighted ventilator variables and their association with clinical outcomes in a multicenter real-world setting.

Costs associated with acute kidney injury in critically Ill neonates with patent Ductus arteriosus: pediatric health information system (PHIS) analysis.

OBJECTIVE: Compare costs of hospitalization between critically-ill neonates with patent ductus arteriosus (PDA) who did and did not develop acute kidney injury (AKI). STUDY DESIGN: Using the Children's Hospital Association's Pediatric Health Information System (PHIS) database, we ascertained the marginal estimated total cost of hospitalization between those who did and did not develop AKI. RESULTS: Query of 49 PHIS centers yielded 14,217 neonates with PDA, 1697 with AKI and 12,520 without AKI. Predictors of cost included AKI, birth weight, ethnicity, race, length of stay (LOS), and Feudtner Complex Chronic Conditions Classification System. LOS was the strongest predictor (AKI: median 71 days [IQR 28-130]; No AKI: 28 days [10-76]; p < 0.01). Neonates with AKI had $48,416 greater costs (95% CI: $43,804-53,227) after adjusting for these predictors (AKI: $190,063, 95% CI $183,735-196,610; No AKI: $141,647, 95% CI $139,931-143,383 l; p < 0.01). CONCLUSION: AKI is independently associated with increased hospital costs in critically-ill neonates with PDA.

The Impact of Timing on Clinical and Economic Outcomes During Inter-ICU Transfer of Acute Respiratory Failure Patients: Time and Tide Wait for No One.

Approximately one in 30 patients with acute respiratory failure (ARF) undergoes an inter-ICU transfer. Our objectives are to describe inter-ICU transfer patterns and evaluate the impact of timing of transfer on patient-centered outcomes. DESIGN: Retrospective, quasi-experimental study. SETTING: We used the Healthcare Cost and Utilization Project State Inpatient Databases in five states (Florida, Maryland, Mississippi, New York, and Washington) during 2015-2017. PARTICIPANTS: We selected patients with International Classification of Diseases, 9th and 10th Revision codes of respiratory failure and mechanical ventilation who underwent an inter-ICU transfer (n = 6,718), grouping as early (≤ 2 d) and later transfers (3+ d). To control for potential selection bias, we propensity score matched patients (1:1) to model propensity for early transfer using a priori defined patient demographic, clinical, and hospital variables. MAIN OUTCOMES: Inhospital mortality, hospital length of stay (HLOS), and cumulative charges related to inter-ICU transfer. RESULTS: Six-thousand seven-hundred eighteen patients with ARF underwent inter-ICU transfer, 68% of whom (n = 4,552) were transferred early (≤ 2 d). Propensity score matching yielded 3,774 well-matched patients for this study. Unadjusted outcomes were all superior in the early versus later transfer cohort: inhospital mortality (24.4% vs 36.1%; p < 0.0001), length of stay (8 vs 22 d; p < 0.0001), and cumulative charges ($118,686 vs $308,977; p < 0.0001). Through doubly robust multivariable modeling with random effects at the state level, we found patients who were transferred early had a 55.8% reduction in risk of inhospital mortality than those whose transfer was later (relative risk, 0.442; 95% CI, 0.403-0.497). Additionally, the early transfer cohort had lower HLOS (20.7 fewer days [13.0 vs 33.7; p < 0.0001]), and lower cumulative charges ($66,201 less [$192,182 vs $258,383; p < 0.0001]). CONCLUSIONS AND RELEVANCE: Our study is the first to use a large, multistate sample to evaluate the practice of inter-ICU transfers in ARF and also define early and later transfers. Our findings of favorable outcomes with early transfer are vital in designing future prospective studies evaluating evidence-based transfer procedures and policies.

School nurse perception of asthma care in school-based telehealth.

OBJECTIVE: School-based telehealth (SBTH) offers an opportunity to overcome traditional barriers to providing comprehensive asthma care for children. Guided by an implementation science framework considering factors internal and external to the school setting, we characterized barriers and facilitators to asthma care within an existing SBTH program available in over 50 under-resourced South Carolina schools. METHODS: This cross-sectional study assessed barriers and facilitators to SBTH asthma care delivery using web-based surveys of school nurses, specifically addressing school implementation of telehealth methods. Surveys evaluated practices and nurse and school-specific factors related to telehealth implementation including perceived barriers, organizational readiness and self-efficacy. Utilizers were schools who completed 1-10 average visits per month while non-utilizers completed less than 1 average visit per month. Descriptive statistics were performed to characterize perceptions in utilizers versus non-utilizers. RESULTS: Of 53 surveys distributed, 36 were completed (68% response rate). Commonly cited barriers included inadequate time due to competing tasks in both utilizers (65%) and non-utilizers (74%) as well as lack of caregiver involvement in care planning (94% of utilizers and 84% of non-utilizers). Of those utilizing specific, relevant telehealth services, schools scored high in perceptions of organizational readiness (n = 24, mean: 24.5/30), self-efficacy (n = 26, mean: 3.6/5) and comfort with identifying students eligible for SBTH (n = 26, mean: 3.5/5). CONCLUSIONS: We identified inadequate nurse time and challenges engaging caregivers as key barriers to implementation of a school-based telehealth asthma program providing care to an under-resourced population. Addressing these barriers when expanding telehealth services may promote utilization of telehealth.

Missing data methods for intensive care unit SOFA scores in electronic health records studies: results from a Monte Carlo simulation.

Aim: Missing data cause problems through decreasing sample size and the potential for introducing bias. We tested four missing data methods on the Sequential Organ Failure Assessment (SOFA) score, an intensive care research severity adjuster. Methods: Simulation study using 2015-2017 electronic health record data, where the complete dataset was sampled, missing SOFA score elements imposed and performance examined of four missing data methods - complete case analysis, median imputation, zero imputation (recommended by SOFA score creators) and multiple imputation (MI) - on the outcome of in-hospital mortality. Results: MI performed well, whereas other methods introduced varying amounts of bias or decreased sample size. Conclusion: We recommend using MI in analyses where SOFA score component values are missing in administrative data research.

A comparison of administrative claims-based risk predictors for pediatric asthma.

OBJECTIVES: Head-to-head comparisons are needed to determine the most accurate and appropriate administrative claims-based exacerbation risk predictor for emergency department (ED) visits and hospitalizations among children with asthma. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed 2013-2014 MarketScan Medicaid data. Children aged 2 to 17 years were included. Seven risk predictors were compared for accuracy in predicting 3-month subsequent ED visits/hospitalizations for asthma: 3-month rolling asthma medication ratio (AMR), Healthcare Effectiveness Data and Information Set (HEDIS) criteria, revised HEDIS criteria, quarterly short-acting ß-agonist (SABA) claims, prior ED visit, prior hospitalization, and prior ED visit or hospitalization. Sensitivity, specificity, positive and negative predictive value (NPV), and percentage of population identified as high risk were compared for each risk predictor utilizing the McNemar test to identify statistically significant differences in risk prediction accuracy. RESULTS: A total of 214,452 children were included; the mean age was 7.8 years. HEDIS and revised HEDIS identified prohibitively large cohorts as high risk (67% and 48%, respectively). For the remaining measures, the NPV range is narrow (97%-99%), indicating high performance at identifying patients who would not benefit from intervention. The ED visit and ED/hospitalization measures have superior sensitivities (44% and 49%, respectively) compared with pharmacy claims-based measures (AMR [5%] and SABA count [10%]). Pharmacy claims-based measures identify a smaller proportion of patients as high risk and maintain high NPV. CONCLUSIONS: Pharmacy-based asthma exacerbation risk predictors such as the AMR and SABA count can rule out low-risk patients with a high degree of specificity and NPV, which is a primary goal of real-time risk monitoring in pediatric asthma.

Nurse Perspectives Regarding Implementation of an Asthma Monitoring Mobile Health Application in the School Setting.

Background: School-based telehealth (SBTH) plays a valuable role in child asthma management, although nurses have concerns with caregiver engagement. Mobile technology (m-health) has potential to improve this engagement. Objective: We identified barriers and key desired features of an asthma m-health application as a supplement to an existing SBTH asthma program in rural settings. Methods: Multimethod design using school nurse surveys and interviews with school and SBTH personnel to describe processes related to implementation of an m-health application. Results: Nurses reported SBTH programs were an ideal setting to identify potential families for m-health. Benefits of caregiver education and engagement and barriers related to technology, smart phone data availability, and family buy-in were described. Desired application features included education on inhaler technique, asthma symptom, and medication adherence reports. Conclusions: The feedback identified from nurses can be incorporated into an asthma m-health program within an SBTH program to facilitate implementation.

Assessing Health Care Utilization and Compliance in Kawasaki Disease.

OBJECTIVE: To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN: We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS: The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS: Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.

Drivers of Start-Up Delays in Global Randomized Clinical Trials.

BACKGROUND: Global, randomized clinical trials are extremely complex. Trial start-up is a critical phase and has many opportunities for delay which adversely impact the study timelines and budget. Understanding factors that contribute to delay may help clinical trial managers and other stakeholders to work more efficiently, hastening patient access to potential new therapies. METHODS: We reviewed the available literature related to start-up of global, Phase III clinical trials and then created a fishbone diagram detailing drivers contributing to start-up delays. The issues identified were used to craft a checklist to assist clinical trial managers in more efficient trial start-up. RESULTS: We identified key drivers for start-up delays in the following categories: regulatory, contracts and budgets, insurance, clinical supplies, site identification and selection, site activation, and inefficient processes/pitfalls. CONCLUSION: Initiating global randomized clinical trials is a complex endeavor, and reasons for delay are well documented in the literature. By using a checklist, clinical trial managers may mitigate some delays and get clinical studies initiated as soon as possible.

Notable Variability in Opioid-prescribing Practices After Common Orthopaedic Procedures.

INTRODUCTION: The purpose of this study was to evaluate nationwide trends and regional variability in opioid prescriptions after common orthopaedic procedures. METHODS: A retrospective analysis of privately insured subjects from the MarketScan database between 2015 and 2016 was conducted. Median oral morphine equivalents and interquartile ranges were analyzed by region for the initial post-op prescriptions and 90-day total prescriptions for opioid-naive patients undergoing the following: carpal tunnel release; anterior cruciate ligament reconstruction; arthroscopic meniscectomy; bimalleolar ankle fracture open reduction and internal fixation; distal radius fracture open reduction and internal fixation; arthroscopic rotator cuff repair; single-level anterior cervical discectomy and fusion; and total shoulder, hip, and knee arthroplasties. We hypothesized that notable regional variability exists with postoperative narcotic prescribing habits. RESULTS: Seventy three thousand nine hundred twenty-one opioid-naive patients were identified. A notable regional variability was observed across the United States in the prescriptions given for all procedures, except total joint arthroplasty. Furthermore, although patients undergoing soft-tissue-only procedures required the fewest refills, patients undergoing total joint arthroplasty required the most. DISCUSSION: Notable regional variability exisits in opioid prescribing patterns for many common orthopaedic procedures. Furthermore, prescriptions were smallest in the region most affected by the opioid epidemic. This information can be used to re-evaluate recommendations, serve as a benchmark for surgeons, and develop institutional and quality improvement guidelines to reduce excess postoperative opioid prescriptions. LEVEL OF EVIDENCE: Level III observational cohort study.

A Longitudinal Examination of the Asthma Medication Ratio in Children with Medicaid.

Background/Objective: An efficient and accurate strategy for identifying children with asthma at high-risk for exacerbation is needed. The objective of this study is to conduct a longitudinal examination of the asthma medication ratio (AMR) (#of controller medication claims/(# of controller medication claims + # of rescue medication claims)) in Medicaid-funded children with asthma. This measure has the potential to be a near real-time risk assessment tool.Methods: We conducted a retrospective analysis of 2013-2014 Truven Health Medicaid data. We analyzed pharmacy and medical claims for a cohort of children with asthma. We identified patients age 2-17 years with at least one claim for an inhaled corticosteroid. We calculated an AMR for rolling 3-month periods and examined the proportion who were classified as low risk (AMR ≥ .5), high-risk (AMR < .5) and no medication claims (no asthma medication claims). Using logistic regression, we tested how the AMR predicted severe exacerbations.Results: 214,452 eligible children were identified. The mean age is 7.8 years. 8-9% had a high-risk AMR in any given period. High-risk AMR is associated with increased odds of a severe exacerbation in the subsequent 3 months (compared to all other children) (OR 1.7-1.9 depending on time period evaluated).Conclusions: In this analysis of Medicaid-insured children with asthma, we found that the AMR is a reliable predictor of exacerbations. This will inform the development of an AMR-based risk assessment and communication intervention.

A propensity-score matched analysis of limb salvage vs amputation for osteosarcoma.

BACKGROUND AND OBJECTIVES: With recent advances in chemotherapy and surgical techniques, the trend in the treatment of osteosarcoma continues to progress towards limb salvage. However, studies comparing limb salvage with amputation continue to be limited by selection bias and small sample sizes. This study utilized propensity-score matching to minimize potential confounders and selection bias to compare the survival rates in patients with osteosarcoma that were treated with amputation vs limb salvage surgery. METHODS: The Surveillance, Epidemiology, and End Results Program was utilized to identify all patients with a diagnosis of extremity osteosarcoma. Patients were matched with demographics, tumor characteristics, and treatment information. These variables were then fitted in a multivariate model and hazard ratios (HR) for overall- and disease-specific mortality was calculated. RESULTS: A total of 4107 patients were identified, of which, 1538 were left after propensity-score matching. Older age, Black race, upper extremity location, and higher American joint committee on cancer (AJCC) class were associated with worse overall- and disease-specific mortality rates (P ≤ .0389). Compared with their matched counterparts, patients treated with amputation had higher overall mortality (HR 1.677; P < .0001) and higher disease-specific mortality (HR 1.678; P < .0001). CONCLUSION: Patients whose tumor characteristics preclude limb salvage have significantly higher overall- and disease-specific mortality rates.

Loop diuretic use among patients with heart failure and type 2 diabetes treated with sodium glucose cotransporter-2 inhibitors.

AIMS: To compare loop diuretic use in patients with comorbid heart failure (HF) and type 2 diabetes (T2D) newly initiated on sodium glucose cotransporter-2 inhibitors (SGLT2Is) versus other oral anti-glycemic agents (AGAs). METHODS: This analysis used 2013-2015 MarketScan Medicare Supplemental claims data. HF and T2D patients were identified and SGLT2I users were propensity score matched to other AGA users. The mean daily dose of loop diuretics in furosemide equivalents was ascertained. For those not on baseline loop diuretics, new use was compared between cohorts. For those on baseline loop diuretics, we assessed patterns of use (increased dose, decreased dose, stable dose, no longer using) at 12-months. RESULTS: A total of 750 SGLT2I users were matched to 750 other AGA users. The distribution of loop diuretic use at mean doses of 0 mg (i.e., no use), ≤20 mg, >20 mg-40 mg, >40 mg-80 mg and >80 mg/day did not differ between cohorts at baseline or 12-months (p > 0.05 for both). SGLT2I use was associated with less new loop diuretic use (22.7% [79/348] vs. 34.0% [132/388]; p = 0.001). For those on loop diuretics at baseline (n = 764), patterns of use at 12-months did not differ between cohorts (p = 0.14). CONCLUSIONS: New loop diuretic use was less frequent among SGLT2I users; however, patterns of loop diuretic use did not differ between cohorts in those on loop diuretics at baseline.

Impact of selective serotonin reuptake inhibitors in the veteran population: 10-year risk outcomes.

AIM: To evaluate the comparative risk of hip fracture or osteoporosis among US Veterans based on selective serotonin reuptake inhibitor (SSRI) exposure. PATIENTS & METHODS: A retrospective cohort study of eligible US Veterans Health Administration patients enrolled in 2003-2004 was performed to examine SSRIs' 2-, 5- and 10-year impact on bone health using multiple logistic regression. RESULTS: Veterans on SSRIs were found to be 56.7% more likely over a 10-year period to suffer a hip fracture (risk ratio: 1.567; 95% CI: 1.464-1.676) and 34.6% more likely to develop osteoporosis (risk ratio: 1.346; 95% CI: 1.319-1.374) when compared with those who were SSRI naive. CONCLUSION: SSRI usage was associated with greater risk of hip fracture and osteoporosis over a 10-year period in the veteran population, with similar effect sizes to smaller studies.