A multicenter randomized trial to compare automatic versus as-needed follow-up for children hospitalized with common infections: The FAAN-C trial protocol.

INTRODUCTION: Physicians commonly recommend automatic primary care follow-up visits to children being discharged from the hospital. While automatic follow-up provides an opportunity to address postdischarge needs, the alternative is as-needed follow-up. With this strategy, families monitor their child's symptoms and decide if they need a follow-up visit in the days after discharge. In addition to being family centered, as-needed follow-up has the potential to reduce time and financial burdens on both families and the healthcare system. As-needed follow-up has been shown to be safe and effective for children hospitalized with bronchiolitis, but the extent to which hospitalized children with other common conditions might benefit from as-needed follow-up is unclear. METHODS: The Follow-up Automatically versus As-Needed Comparison (FAAN-C, or "fancy") trial is a multicenter randomized controlled trial. Children who are hospitalized for pneumonia, urinary tract infection, skin and soft tissue infection, or acute gastroenteritis are eligible to participate. Participants are randomized to an as-needed versus automatic posthospitalization follow-up recommendation. The sample size estimate is 2674 participants and the primary outcome is all-cause hospital readmission within 14 days of discharge. Secondary outcomes are medical interventions and child health-related quality of life. Analyses will be conducted in an intention-to-treat manner, testing noninferiority of as-needed follow-up compared with automatic follow-up. DISCUSSION: FAAN-C will elucidate the relative benefits of an as-needed versus automatic follow-up recommendation, informing one of the most common decisions faced by families of hospitalized children and their medical providers. Findings from FAAN-C will also have implications for national quality metrics and guidelines.

Use of central venous access devices outside of the pediatric intensive care units.

BACKGROUND: Central venous access devices (CVAD) are associated with central line associated bloodstream infection (CLABSI) and venous thromboembolism (VTE). We identified trends in non-intensive care unit (ICU) CVAD utilization, described complication rates, and compared resources between low and high CVAD sites. METHODS: We combined data from the Pediatric Health Information System (PHIS) database and surveys from included hospitals. We analyzed 10-year trends in CVAD encounters for non-ICU children between 01/2012-12/2021 and described variation and complication rates between 01/2017-12/2021. Using Fisher's exact test, we compared resources between low and high CVAD users. RESULTS: CVAD use decreased from 6.3% to 3.8% of hospitalizations over 10 years. From 2017-2021, 67,830 encounters with CVAD were identified. Median age was 7 (IQR 2-13) years; 46% were female. Significant variation in CVAD utilization exists (range 1.4-16.9%). Rates of CLABSI and VTE were 4.0% and 3.4%, respectively. Survey responses from 33/41 (80%) hospitals showed 91% had vascular access teams, 30% used vascular access selection guides, and 70% used midline/long peripheral catheters. Low CVAD users were more likely to have a team guiding device selection (100% vs 43%, p = 0.026). CONCLUSIONS: CVAD utilization decreased over time. Significant variation in CVAD use remains and may be associated with hospital resources. IMPACT: Central venous access device (CVAD) use outside of the ICU is trending down; however, significant variation exists between institutions. Children with CVADs hospitalized on the acute care units had a CLABSI rate of 4% and VTE rate of 3.4%. 91% of surveyed institutions have a vascular access team; however, the services provided vary between institutions. Even though 70% of the surveyed institutions have the ability to place midline/long peripheral catheters, the majority use these catheters less than a few times per month. Institutions with low CVAD use are more likely to have a vascular access team that guides device selection.

Prioritization of Randomized Clinical Trial Questions for Children Hospitalized With Common Conditions: A Consensus Statement.

Importance: There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions. Objective: To identify the most important and feasible RCT questions for children hospitalized with common conditions. Design, Setting, and Participants: For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions. Main Outcomes and Measures: The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility. Results: Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children's hospital (n = 14) and community hospital (n = 13) pediatricians, parents of hospitalized children (n = 4), other clinicians (n = 2), biostatisticians (n = 2), and other researchers (n = 11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis). Conclusions and Relevance: This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

Transition to Weight-Based High-Flow Nasal Cannula Use Outside of the ICU for Bronchiolitis.

Importance: Most children's hospitals have adopted weight-based high-flow nasal cannula (HFNC) bronchiolitis protocols for use outside of the intensive care unit (ICU) setting. Whether these protocols are achieving their goal of reducing bronchiolitis-related ICU admissions remains unknown. Objective: To measure the association between hospital transition to weight-based non-ICU HFNC use and subsequent ICU admission. Design, Setting, and Participants: This multicenter retrospective cohort study was conducted with a controlled interrupted time series approach and involved 18 children's hospitals that contribute data to the Pediatric Health Information Systems database. The cohort included patients aged 0 to 24 months who were hospitalized with a diagnosis of bronchiolitis between January 1, 2010, and December 31, 2021. Data were analyzed from July 2023 to January 2024. Exposure: Hospital-level transition from ICU-only to weight-based non-ICU protocol for HFNC use. Data for the ICU-only group were obtained from a previously published survey. Main Outcomes and Measures: Proportion of patients with bronchiolitis admitted to the ICU. Results: A total of 86 046 patients with bronchiolitis received care from 10 hospitals in the ICU-only group (n = 47 336; 27 850 males [58.8%]; mean [SD] age, 7.6 [6.2] years) and 8 hospitals in the weight-based protocol group (n = 38 710; 22 845 males [59.0%]; mean [SD] age, 7.7 [6.3] years). Mean age and sex were similar for patients between the 2 groups. Hospitals in the ICU-only group vs the weight-based protocol group had higher proportions of Black (26.2% vs 19.8%) and non-Hispanic (81.6% vs 63.8%) patients and patients with governmental insurance (68.1% vs 65.9%). Hospital transition to a weight-based HFNC protocol was associated with a 6.1% (95% CI, 8.7%-3.4%) decrease per year in ICU admission and a 1.5% (95% CI, 2.8%-0.1%) reduction per year in noninvasive positive pressure ventilation use compared with the ICU-only group. No differences in mean length of stay or the proportion of patients who received invasive mechanical ventilation were found between groups. Conclusions and Relevance: Results of this cohort study of hospitalized patients with bronchiolitis suggest that transition from ICU-only to weight-based non-ICU HFNC protocols is associated with reduced ICU admission rates.

Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic.

IMPORTANCE: Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes. OBJECTIVES: To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity. DESIGN, SETTING, AND PARTICIPANTS: This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021. EXPOSURE: Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021). MAIN OUTCOMES AND MEASURES: The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis. RESULTS: The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic. CONCLUSIONS AND RELEVANCE: In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

Trends in Low-Value Care Among Children's Hospitals.

BACKGROUND AND OBJECTIVES: Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends. METHODS: This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC. RESULTS: There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures. CONCLUSIONS: LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.

Misclassification of Both Influenza Infection and Oseltamivir Exposure Status in Administrative Data.

This cross-sectional study examines documented hospitalization for influenza and administration of neuraminidase inhibitors in US children.