Adolescent Suicide-Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death.

Purpose of Review: This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers. Recent Findings: The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide. Summary: Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

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.

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.

Insurance Type Influences Access to Biologics and Healthcare Utilization in Pediatric Crohn's Disease.

Background: The objective of this study is to determine if there is an association between insurance status and access to biologics among children with Crohn's disease (CD). Additionally, we seek to determine differences in healthcare utilization between these groups, utilizing a national sample of children with CD. Methods: Children aged 8-18 with a diagnosis of CD were identified from 2012-2016 Truven Health MarketScan (IBM Watson Health). Patients were classified into Public/Medicaid or as Commercial/Privately Insured. Descriptive statistics were compared between groups and sensitivity analysis performed using inverse probability of treatment weighting. Adjusted differences in healthcare utilization were estimated by multiple linear regression models. Results: We identified 6163 patients with a diagnosis of CD. There were no significant differences in each payer group's demographic characteristics, comorbidities, or surgery rates. Over the 18-month follow-up period, 132 (20.4%) subjects in the public insurance group and 851 (15.4%) children in the private insurance group received biologics. Medicaid patients were 39% more likely to receive a biologic agent within 18 months of diagnosis compared to privately insured children (P = .0004). Postdiagnosis rates of hospitalizations and Emergency Department visits were significantly higher for the Medicaid group. Conclusions: In this national sample of children with CD, publicly insured children were more likely to receive a biologic within 18 months of diagnosis compared to children with private insurance. At all points in time, publicly insured children also utilized emergency room services and required hospitalization at a significantly higher rate.

A Cost Comparison of Infliximab Versus Intravenous Immunoglobulin for Refractory Kawasaki Disease Treatment.

BACKGROUND AND OBJECTIVES: In 10% to 20% of cases, Kawasaki disease is refractory to intravenous immunoglobulin (IVIg), an expensive medication under a national shortage. Data suggest that infliximab is a viable alternative to a second dose of IVIg, with similar efficacy and safety. We compared the cost of a second IVIg dose to that of infliximab in the treatment of refractory Kawasaki disease (rKD). METHODS: A decision analysis model was used to compare rKD treatments: a second dose of IVIg at 2 g/kg versus infliximab at 10 mg/kg. Infliximab monitoring times were 24, 36, and 48 hours. Direct hospital costs beginning at rKD diagnosis were estimated by using 2016-2017 Truven MarketScan data. Redbook was used for drug costs. Calculations were applied to 3 hypothetical cohorts of 100 patients aged 2 (12.5 kg), 4 (16 kg), and 8 years (25.5 kg). Indirect costs included parental missed workdays. RESULTS: The total direct cost for children receiving IVIg was $1 677 801, $1 791 652, and $2 100 675 for the 2-, 4-, and 8-year-old cohorts. The direct cost of infliximab with 24 hours of monitoring was $853 042, $899 096, and $1 024 101, respectively. A 20% bidirectional sensitivity analysis revealed stability of our model, with overall cost savings with use of infliximab. With monitoring 48 hours after infliximab treatment, 20% changes in length of stay (LOS) tipped the balance for the 2- and 4-year-old cohorts. Overall, IVIg and infliximab LOS had the most influence on our model. CONCLUSIONS: Infliximab has potential to yield shorter LOS and significant cost savings in the treatment of rKD. Infliximab treatment, followed by 24 hours of monitoring, nearly halved hospital costs, regardless of age.

Improving the Frequency and Documentation of Gun Safety Counseling in a Resident Primary Care Clinic.

OBJECTIVE: Increase the frequency and documentation of gun safety discussions during well-child checks in the pediatric primary care resident clinic to 50% within 6 months. METHODS: This is a quality improvement study in a pediatric resident continuity clinic. Before implementing any interventions, a survey was conducted to understand residents' attitudes and practices regarding gun safety screening and counseling. Interventions included a parent safety survey, Be SMART materials in clinic, and a prompt embedded into Electronic Health Record templates. Chart reviews were conducted to determine frequency of gun safety discussion. Resident self-reported comfort with gun safety counseling was also evaluated. RESULTS: A statistical process control chart was generated to track documentation and found the baseline mean rate of gun safety discussions during well-child checks was 3%. Rates increased following the addition of the Electronic Health Record prompt, with the mean further increased to 84% in July 2019. A sustained rate of over 75% was achieved through February 2020. Over 4 study months, the proportion of trainees reporting feeling very uncomfortable/uncomfortable with gun safety counseling decreased from 22% to 15%. The Be SMART program was identified as a key intervention increasing gun safety counseling. CONCLUSIONS: Our study identified an effective approach to improving the frequency and documentation of gun safety discussions in an academic primary care setting, providing a unique blueprint for firearm screening and safe storage counseling success. Ultimately, we believe this will increase safe storage behaviors in the home and reduce risks of child death from firearms.

Measures of ED utilization in a national cohort of children.

OBJECTIVES: Emergency department (ED) utilization is often used as an indicator of poor chronic disease control and/or poor quality of care. We sought to determine if 2 ED utilization measures identify clinically or demographically different populations of children. STUDY DESIGN: Retrospective cohort study utilizing IBM Health/Truven MarketScan Medicaid data. METHODS: Children and adolescents were categorized based on the presence and complexity of chronic medical conditions using the 3M Clinical Risk Group system. Children and adolescents were categorized as high ED utilizers using 2 measures: (1) ED reliance (EDR) (number of ED visits / [number of ED visits + number of ambulatory visits]; EDR >0.33 = high utilizer) and (2) visit counts (≥3 ED visits = high utilizer). Logistic regression models identified patient factors associated with each of our outcome measures. RESULTS: A total of 5,438,541 children and adolescents were included; 65% were without chronic disease (WO-CD), 32% had noncomplex chronic disease (NC-CD), and 3% had complex chronic disease (C-CD). EDR identified 18% as frequent utilizers compared with 7% by the visit count measure. In the visit count model, children younger than 2 years and those classified as WO-CD and NC-CD were less likely to be identified as high utilizers. Conversely, in the EDR model, children and adolescents 2 years and older and those classified as WO-CD and NC-CD were more likely to be classified as high utilizers. CONCLUSIONS: The ED utilization measures identify clinically and demographically different groups of patients. Future studies should consider the medical complexity of the population being studied before choosing the most appropriate measure to employ.

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.

Parent Preferences for Methods and Content of Mobile Technology-Based Asthma Medication Adherence Intervention.

OBJECTIVES: Mobile technology-based asthma medication adherence interventions can be targeted to children during periods of high risk, including the transition from hospital to home or when refill behavior suggests declining adherence. Our objective was to develop insight into parent use of mobile technology and their preferences for a mobile technology-based asthma intervention. METHODS: By using qualitative methods, 20 interviews of parents of children with asthma were conducted. The open-ended, semistructured interview guides included questions about current mobile technology use, barriers to controller medication adherence, and preferences for methods and content of a mobile technology-based asthma intervention. Using grounded theory methodology, investigators coded the transcripts and identified emerging themes. RESULTS: Twenty parents completed interviews. Half of the children were 7 to 12 years old. Eighty percent had public insurance. Sixty-five percent had a previous hospitalization. Three major themes were identified: chronic disease management assistance, distinct preferences for risk communication, and electronic reachability. Chronic disease management assistance included parents recognizing that busy lifestyles contribute to adherence challenges and welcoming a program to assist them. Distinct preferences for risk communication included a preference for 2-way communication via text message or phone call at least monthly. Under the theme of electronic reachability, all enrolled parents had smartphones and used them daily. CONCLUSIONS: Parents of children with asthma are open to communicating with asthma providers through mobile technology. This information can be used to inform the development of mobile technology-based interventions to improve care for children with asthma during periods of high risk, including the transition from hospital to home.

A longitudinal examination of the asthma medication ratio in children.

OBJECTIVES: The asthma medication ratio (AMR) (number of controller medications / [number of controller medications + number of rescue medications]) can be calculated using claims data. This measure has not previously been studied longitudinally. Our objective is to conduct a longitudinal examination of the AMR in a large national cohort of children with asthma. STUDY DESIGN: Retrospective analysis of pharmacy and medical claims data. METHODS: Using 2013-2014 TruvenHealth MarketScan data, we identified children with asthma. Beginning with the month of first controller claim, we calculated an AMR for each rolling 3-month period and each rolling 6-month period and examined the proportion who had AMRs classified as low-risk (≥0.5), high-risk (<0.5), and missing for each period. Using logistic regression, we tested how a rolling AMR predicted a child's hospitalization or emergency department (ED) visit for asthma. RESULTS: We identified 197,316 patients aged 2 to 17 years with a claim for a controller. AMRs were relatively stable over time, with the majority of patients remaining in the same AMR category through a 12-month period. Using both the rolling 3-month and 6-month AMRs, a higher proportion of patients with high-risk AMRs (9.6% and 9.5%, respectively) had an ED visit or hospitalization compared with patients with low-risk (5.0% and 5.7%) and missing (3.5% and 3.2%) AMRs (P <.0001). Using logistic regression, the 3-month AMR is more strongly associated with subsequent ED visit or hospitalization than the 6-month AMR. CONCLUSIONS: AMR-based risk assignment is relatively stable over time. Three-month AMR calculation periods appear to provide the most accurate assessment of risk. Children with missing AMRs likely have inactive asthma and are at the lowest risk for emergent asthma visits.

Inhaled corticosteroid prescribing in a pediatric emergency department: Sustained success and prescription filling rates.

OBJECTIVE: To determine if improvement in Inhaled Corticosteroid (ICS) prescribing in the pediatric emergency department (PED) can be sustained after transition from intense intervention to low-intervention phase, and to determine ICS fill rates. METHODS: A Quality Improvement (QI) project began in Aug 2012. Results through Feb 2014 were previously published. In Feb 2014 interventions were scaled back to determine the sustainability of QI success. Eligible patients included children aged 2-17 seen in the PED for asthma between Feb 2014 and Sept 2016. The primary change when moving to the low-intervention phase was stopping monthly attending feedback. The primary outcome was the proportion of patients who were prescribed an ICS at the time of PED discharge. The secondary objective of this study was to determine the proportion of patients who filled their ICS prescription in the 6 months following Emergency Department (ED) visit. RESULTS: The goal rate of ICS prescribing was 75%. After transition to the low-intervention phase, the ICS prescribing rate was maintained at a median of 79% through Sept 2016. ICS fill rate in the first 30 days following ED visit was 89%, although this quickly fell to below 40% for months 2-6. CONCLUSIONS: The ICS prescribing rate remained the goal of 75% over a 2.5-year period after transition to a low-intervention phase. High ICS fill rates immediately after ED visit have been demonstrated. However, rapid decline in these rates over subsequent months suggests a need for future efforts to focus on long-term ICS adherence among children with ED visits for asthma.

Inhaled Corticosteroid Claims and Outpatient Visits After Hospitalization for Asthma Among Commercially Insured Children.

OBJECTIVE: To determine rates of inhaled corticosteroid (ICS) claims and outpatient follow-up after asthma hospitalization among commercially insured children. METHODS: We conducted a retrospective cohort analysis of children hospitalized for asthma using 2013 national Truven MarketScan data. Covariates included age, sex, region, length of stay, and having an ICS claim within 35 days before hospitalization. Outcome variables were a claim for any ICS-containing medication and outpatient visit within 30 days after discharge. Multivariable analysis used logistic regression. RESULTS: A total of 5471 children aged 2 to 17 were included; 61% were boys, and mean age was 6.8 years. Forty-one percent had a claim for an ICS and 76% had an outpatient visit within 30 days after hospital discharge. In multivariable analysis, children who had an ICS claim within 35 days before the hospitalization were more likely to have an ICS claim within 30 days after discharge (relative risk [RR] 1.3, 95% confidence interval [CI] 1.2-1.5). The strongest predictor of an ICS claim within 30 days after discharge was attendance at an outpatient appointment (RR 1.4, 95% CI 1.3-1.6). Children aged 2 to 6 were more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.1-1.2). Children with an ICS claim before admission were also more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.004-1.1). CONCLUSIONS: In this national sample of commercially insured children with asthma, rates of ICS claims after hospitalization are low despite high rates of outpatient visits. Both inpatient and outpatient physicians must play a role in increasing ICS adherence in this high-risk population of children with asthma.

A Cost-Effectiveness Analysis of Obtaining Blood Cultures in Children Hospitalized for Community-Acquired Pneumonia.

OBJECTIVE: To determine the clinical utility and cost-effectiveness of universal vs targeted approach to obtaining blood cultures in children hospitalized with community-acquired pneumonia (CAP). STUDY DESIGN: We conducted a cost-effectiveness analysis using a decision tree to compare 2 approaches to ordering blood cultures in children hospitalized with CAP: obtaining blood cultures in all children admitted with CAP (universal approach) and obtaining blood cultures in patients identified as high risk for bacteremia (targeted approach). We searched the literature to determine expected proportions of high-risk patients, positive culture rates, and predicted bacteria and susceptibility patterns. Our primary clinical outcome was projected rate of missed bacteremia with associated treatment failure in the targeted approach. Costs per 100 patients and annualized costs on the national level were calculated for each approach. RESULTS: The model predicts that in the targeted approach, there will be 0.07 cases of missed bacteremia with treatment failure per 100 patients, or 133 annually. In the universal approach, 118 blood cultures would need to be drawn to identify 1 patient with bacteremia, in which the result would lead to a meaningful antibiotic change compared with 42 cultures in the targeted approach. The universal approach would cost $5178 per 100 patients or $9,214,238 annually. The targeted approach would cost $1992 per 100 patients or $3,545,460 annually. The laboratory-related cost savings attributed to the targeted approach would be projected to be $5,668,778 annually. CONCLUSIONS: This decision analysis model suggests that a targeted approach to obtaining blood cultures in children hospitalized with CAP may be clinically effective, cost-saving, and reduce unnecessary testing.

Lower rates of EMR use in rural hospitals represent a previously unexplored child health disparity.

OBJECTIVES: Rural hospitals face significant barriers to adoption of advanced-stage electronic medical records (EMRs), which may translate to an unexplored disparity for children in rural hospitals. Our objective was to determine whether children hospitalized in rural settings are less likely to be cared for using advanced-stage EMRs. METHODS: We merged the 2009 Healthcare Cost and Utilization Project Kids Inpatient Dataset with the 2009 Healthcare Information and Management Systems Society database. Logistic regression determined the independent relationship between receiving care in a rural hospital and advanced-stage EMRs. RESULTS: A total of 430 055 (9.3%) of the 4 605 454 pediatric discharges were rural. Logistic regression analysis determined that even when an extensive list of various patient and hospital characteristics are accounted for, rurality continues to be a strong predictor of a child's care without advanced-stage EMRs (odds ratio 0.3; 95% confidence interval, 0.2-0.5). CONCLUSIONS: Children hospitalized in a rural hospital are less than half as likely to be treated using advanced-stage EMRs. A focus of government and hospital policies to expand the use of EMRs among rural hospitals may reduce this child health care disparity.

Cost-effectiveness analysis of annual Trichomonas vaginalis screening and treatment in HIV-positive women to prevent HIV transmission.

BACKGROUND: Because of a high incidence of Trichomonas infection among HIV-positive women, annual screening and treatment are recommended. Trichomonas infection is associated with a 2-fold risk of HIV transmission. The objective of this study was to determine if annual screening is cost-effective for the prevention of new HIV cases in susceptible male partners secondary to Trichomonas infection in HIV-positive women. METHODS: A decision tree analysis was constructed to model the costs of Trichomonas screening, treatment, and follow-up. 200 women cycled through the model for a period of 12 months. One hundred women were unscreened and 100 were screened and treated per recommendations. RESULTS: Annual Trichomonas screening and treatment saves US $553 (US $475- US $645) per woman in the prevention of HIV transmission to male partners. The cost-effectiveness of this strategy was maintained across all assumptions in a sensitivity analysis. CONCLUSIONS: Trichomonas screening and treatment for the purpose of decreasing new HIV infections is not only cost-effective but also cost saving in HIV-positive women. If Centers for Disease Control and Prevention treatment guidelines were followed in all HIV-positive women living in the United States, the lifetime cost of new HIV infections prevented would approximate US $159,264,000 and could potentially prevent new HIV cases secondary to female-to-male transmissions.

Quality improvement methods improve inhaled corticosteroid prescribing in the emergency department.

OBJECTIVE: Inhaled corticosteroids (ICS) are underutilized among persistent asthmatics. Because of low outpatient follow-up rates after Emergency Department (ED) visits, children are unlikely to be prescribed ICS by their primary care physician after an acute exacerbation. ED physicians have the opportunity to contribute to the delivery of preventive care in the acute care setting. Our objective was to evaluate if quality improvement (QI) methods could improve the rate of ICS initiation at ED discharge. METHODS: Within the Pediatric ED (PED) at a tertiary children's hospital, QI methods were used to encourage ICS prescribing at the time of ED discharge. Interventions focused on education at both the attending physician and resident level, process improvements designed to streamline prescribing, and directed provider feedback. This involved multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed monthly to determine ICS prescribing rates. The effect of our interventions on prescribing rate was tracked over time using a run chart. RESULTS: Following our interventions, the ICS initiation rate for children seen in and discharged home from the ED with an acute asthma exacerbation increased from a baseline median rate of 11.25% to a median rate of 79% representing a significant, non-random improvement. The ICS initiation rate has been sustained for 8 months over our goal rate of 75%. CONCLUSIONS: This study demonstrates that QI methods can be used to increase inhaled corticosteroid initiation rate at the time of ED discharge and, thus, improve the delivery of preventive asthma care in the acute care setting.