Communication Strategies to Improve Antibiotic Prescribing in Pediatric Urgent Care Centers.

OBJECTIVE: Urgent care (UC) clinicians frequently prescribe inappropriate antibiotics for upper respiratory illnesses. In a national survey, pediatric UC clinicians reported family expectations as a primary driver for prescribing inappropriate antibiotics. Communication strategies effectively reduce unnecessary antibiotics while increasing family satisfaction. We aimed to reduce inappropriate prescribing practices in otitis media with effusion (OME), acute otitis media (AOM), and pharyngitis in pediatric UC clinics by a relative 20% within 6 months using evidence-based communication strategies. METHODS: We recruited participants via e-mails, newsletters, and Webinars from pediatric and UC national societies. We defined antibiotic-prescribing appropriateness based on consensus guidelines. Family advisors and UC pediatricians developed script templates based on an evidence-based strategy. Participants submitted data electronically. We reported data using line graphs and shared deidentified data during monthly Webinars. We used χ 2 tests to evaluate change in appropriateness at the beginning and end of the study period. RESULTS: The 104 participants from 14 institutions submitted 1183 encounters for analysis in the intervention cycles. Using a strict definition of inappropriateness, overall inappropriate antibiotic prescriptions for all diagnoses trended downward from 26.4% to 16.6% ( P = 0.13). Inappropriate prescriptions trended upward in OME from 30.8% to 46.7% ( P = 0.34) with clinicians' increased use of "watch and wait" for this diagnosis. Inappropriate prescribing for AOM and pharyngitis improved from 38.6% to 26.5% ( P = 0.03) and 14.5% to 8.8% ( P = 0.44), respectively. CONCLUSIONS: Using templates to standardize communication with caregivers, a national collaborative decreased inappropriate antibiotic prescriptions for AOM and had downward trend in inappropriate antibiotic prescriptions for pharyngitis. Clinicians increased the inappropriate use of "watch and wait" antibiotics for OME. Future studies should evaluate barriers to the appropriate use of delayed antibiotic prescriptions.

Antibiotic Prescribing Patterns for Pediatric Urgent Care Clinicians.

OBJECTIVE: Previous studies have reported high rates of inappropriate antibiotic prescriptions in urgent care (UC). Specific prescribing patterns for the most common diagnoses are not known. The aim of the study is to determine the diagnoses for which antibiotics are prescribed in pediatric UC settings. METHODS: We recruited pediatric UC providers via email to participate in a national multisite quality improvement study. Participants completed a survey on 10 consecutive encounters in which an antibiotic was given between March and May 2018. Encounters in which only topical antibiotics were prescribed were excluded. We categorized the encounters into 3 previously established tiers to determine appropriateness of antibiotic use. The tiers represent a descending order for antibiotic need based on diagnoses, with the first tier representing diagnoses almost always requiring antibiotics and the third tier representing diagnoses when an antibiotic is almost never required. We reported the diagnoses and frequency of antibiotic prescription within each tier. RESULTS: The 157 providers from 20 institutions submitted a total of 2809 encounters. We excluded 339 encounters in which only topical antibiotics were prescribed. Most diagnoses fell into the tier 2 category (85.81%), with only 9.12% in tier 1 and 5.06% in tier 3. The most common diagnoses reported were acute otitis media (48.96%), pharyngitis (25.09%), and skin and soft tissue infections (7.29%). CONCLUSIONS: In this sample of pediatric UC encounters, only 5% of diagnoses receiving antibiotic prescriptions were made up of tier 3 diagnoses, determined to almost never require antibiotics. While viral respiratory infections have been reported to frequently be treated with antibiotics in general UC centers, our study of pediatric UC centers showed that this was infrequent. However, otitis media with effusion and otalgia should be further investigated. With most antibiotic prescriptions being tier 2 diagnoses, pediatric UC providers can use evidence-based prescribing practices, shared decision making, and contingency plans to reduce unnecessary antibiotic exposure.

Pediatric Urgent Care Center Management of Traumatic Injuries in Infants and Children: Adherence to Evidence-Based Practice Guidelines.

OBJECTIVES: To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage. METHODS: A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines. RESULTS: Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care. CONCLUSIONS: Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.

A Multisite Collaborative to Decrease Inappropriate Antibiotics in Urgent Care Centers.

BACKGROUND: Urgent care (UC; a convenient site to receive care for ambulatory-sensitive) centers conditions; however, UC clinicians showed the highest rate of inappropriate antibiotic prescriptions among outpatient settings according to national billing data. Antibiotic prescribing practices in pediatric-specific UC centers were not known but assumed to require improvement. The aim of this multisite quality improvement project was to reduce inappropriate antibiotic prescribing practices for 3 target diagnoses in pediatric UC centers by a relative 20% by December 1, 2019. METHODS: The Society of Pediatric Urgent Care invited pediatric UC clinicians to participate in a multisite quality improvement study from June 2019 to December 2019. The diagnoses included acute otitis media (AOM), otitis media with effusion, and pharyngitis. Algorithms based on published guidelines were used to identify inappropriate antibiotic prescriptions according to indication, agent, and duration. Sites completed multiple intervention cycles from a menu of publicly available antibiotic stewardship materials. Participants submitted data electronically. The outcome measure was the percentage of inappropriate antibiotic prescriptions for the target diagnoses. Process measures were use of delayed antibiotics for AOM and inappropriate testing in pharyngitis. RESULTS: From 20 UC centers, 157 providers submitted data from 3833 encounters during the intervention cycles. Overall inappropriate antibiotic prescription rates decreased by a relative 53.9%. Inappropriate antibiotic prescribing decreased from 57.0% to 36.6% for AOM, 54.6% to 48.4% for otitis media with effusion, and 66.9% to 11.7% for pharyngitis. CONCLUSIONS: Participating pediatric UC providers decreased inappropriate antibiotic prescriptions from 60.3% to 27.8% using publicly available interventions.

Understanding trust between pediatric hospitalists and outpatient clinicians during hospital admissions: A multisite qualitative analysis.

BACKGROUND: During transitions between sites of care, clinicians must build trust with colleagues to make decisions that ensure safe, high-quality care. OBJECTIVES: This study explored factors that could influence trust between outpatient clinicians and pediatric hospitalists when children are referred for hospital admission. DESIGN, SETTING, AND PARTICIPANTS: We conducted an analysis of 41 semistructured interviews with outpatient clinicians and pediatric hospitalists from May 2020 through October 2021 across three healthcare systems participating in a multisite comparative effectiveness study of pediatric direct and emergency department admissions. INTERVENTION, MAIN OUTCOMES, AND MEASURES: Qualitative interviews. A conceptual model for trust between outpatient clinicians and pediatric hospitalists during hospital admission referral. Interviews were professionally transcribed, verified for accuracy, and analyzed using a combination of inductive and deductive. RESULTS: We identified two primary domains: (1) interpersonal trust and (2) trust-by-proxy. Interpersonal trust included five relational factors that influenced collaboration between clinicians: antecedent relationships, confidence in others clinical abilities, understanding others' practice culture, recognition of available resources, and power dynamic. An individual clinicians' assessment of risk and past clinical experiences also influenced trust during clinical decision-making. Trust-by-proxy represented system-level factors that could influence trust, independent of any pre-existing relationships, including communication infrastructure, guidelines and protocols, the organizational culture, and professional courtesy. CONCLUSION: Interpersonal and system-level factors influence trust between outpatient clinicians and hospitalists during decision-making encounters. System-level factors may serve as a proxy for trust when clinicians do not have pre-existing interpersonal relationships. These factors could be explored as an explicit target of interventions to improve interdisciplinary collaboration and decision-making between hospitalists and primary care clinicians.

Pediatric Urgent Care Providers' Approach to Antibiotic Stewardship: A National Survey.

BACKGROUND: Outpatient antibiotic prescribing for acute respiratory conditions is highest in urgent care settings; however, this has not been studied among pediatric urgent cares. The objective of this study was to evaluate pediatric urgent care providers' perceptions of antibiotic stewardship. METHODS: Members of the Society for Pediatric Urgent Care were recruited via email to participate in a quality improvement antibiotic stewardship project. A preimplementation survey was sent to participants via email in March 2019 to evaluate perceptions on antibiotic stewardship. Descriptive statistics were used to analyze the survey responses. RESULTS: A total of 156 providers completed the survey; 83% were board-certified pediatricians. Almost all (98%) indicated that antibiotic stewardship interventions are important for optimizing antibiotic use in urgent care. More than half (53%) indicated that their urgent care provided guidelines for prescribing antibiotics for acute respiratory tract infections. Treating patients with an underlying complex medical condition was the most common reason (21%) providers would deviate from guidelines. The most commonly cited barriers to appropriate prescribing for acute respiratory infections were patient expectations (93%), psychosocial barriers (40%), lack of clear evidence-based recommendations (15%), and lack of access to guidelines on prescribing (15%). CONCLUSIONS: Parental expectation of receiving antibiotics was viewed as the most common barrier to appropriate prescribing. These findings should be used to target directed interventions such as shared decision making and communication training to support appropriate antibiotic prescribing in pediatric urgent care.

Urgent Care: A Valuable New Setting for Training Physician Assistant Students.

PURPOSE: The purpose of this study was to assess physician assistant (PA) students' perceptions of using a pediatric urgent care clinic for their pediatric acute care experience. METHODS: PA students were surveyed on completion of their pediatric urgent care rotations (June 2017 to March 2020). Positive perception was ≥4 on a 5-point scale or ≥80% on agreement for dichotomous variables. Qualitative question responses were open coded for positive themes and opportunities for improvement. RESULTS: Of the 32 students, 29 (90.6%) completed evaluations. Students reported an overall positive perception: patient care, 4.66 (standard deviation [SD] 0.61); system-based practice, 4.76 (SD 0.44); professionalism, 4.90 (SD 0.31); medical knowledge, 4.90 (SD 0.31); and practice-based learning and improvement, 4.66 (SD 0.61). However, interpersonal and communication skills were rated positively on only 65.5% of the evaluations. CONCLUSIONS: An academic pediatric urgent care clinic was regarded positively by PA students as a novel setting to complete a pediatric acute care rotation, but students required more opportunities to work collaboratively.

Demographic Characteristics Among Members of Patient Family Advisory Councils at a Pediatric Health System.

Patient Family Advisory Councils (PFACs) are groups of patients, families, and clinical health system leaders collaborating to improve the quality, safety, and experience of care. Best practices encourage PFAC membership to reflect the diversity of the communities served. A cross-sectional survey was conducted from September 2019 to January 2020 collecting demographic characteristics of the members of a pediatric health system's 17 PFACs. Of the 93 respondents (71.5%), notable inequities were racial (4.8% adult PFAC members vs. 17.4% patients were Black) and financial (adult PFAC median annual income was >$100,000 compared to the community median $77,589). The governing family advisory board used this information to codesign interventions to achieve the ideal state of inclusive excellence by identifying barriers for participation for the Black community, recruiting and retaining diverse board members, and continuous monitoring to maintain a diverse board representation.

Improving Communication for Admissions From Urgent Care to Inpatient Using a Structured Handoff.

BACKGROUND: Previous studies reveal that ineffective communication contributes to patient-safety events. Structured handoffs improve communication during shift change and transfers from outpatient clinics to emergency departments. We aimed to improve the perceived quality of admission handoffs from a baseline of 22.2% to 50% by the end of the study period through use of a standardized template between urgent care (UC) and inpatient providers. METHODS: We used quality improvement methodology to identify key themes (clarity in illness severity, organization, completeness, and pace) that contribute to decreased quality communication. A survey to evaluate the perception of communication and key themes between the groups was administered. During the 15-month quality improvement study at a tertiary pediatric institution, we implemented a handoff tool with visual aids. Givers of information received formal training. Participants received iterative performance feedback. A control chart was used to monitor fidelity to the handoff tool. We used statistical analyses to compare changes in perceived communication between provider types before and after implementation of the handoff tool. RESULTS: Both UC and inpatient providers had an increased rate of positive perceptions in the overall quality of communication after 12 months of using the admission handoff tool (22% vs 67.3%; P = .01). Complete fidelity to the admission handoff tool increased over time. There was no change in mean duration of handoff (4 minutes) after implementing the structured handoff. CONCLUSIONS: A structured handoff during admission of pediatric patients from an off-site UC to inpatient setting improved the perception of the quality of admission handoff communication.

Assessment of holographic microscopy for quantifying marine particle size and concentration.

Holographic microscopy has emerged as a tool for in situ imaging of microscopic organisms and other particles in the marine environment: appealing because of the relatively larger sampling volume and simpler optical configuration compared to other imaging systems. However, its quantitative capabilities have so far remained uncertain, in part because hologram reconstruction and image recognition have required manual operation. Here, we assess the quantitative skill of our automated hologram processing pipeline (CCV Pipeline), to evaluate the size and concentration measurements of environmental and cultured assemblages of marine plankton particles, and microspheres. Over 1 million particles, ranging from 10 to 200 µm in equivalent spherical diameter, imaged by the 4-Deep HoloSea digital inline holographic microscope (DIHM) are analyzed. These measurements were collected in parallel with a FlowCam (FC), Imaging FlowCytobot (IFCB), and manual microscope identification. Once corrections for particle location and nonuniform illumination were developed and applied, the DIHM showed an underestimate in ESD of about 3% to 10%, but successfully reproduced the size spectral slope from environmental samples, and the size distribution of cultures (Dunaliella tertiolecta, Heterosigma akashiwo, and Prorocentrum micans) and microspheres. DIHM concentrations (order 1 to 1000 particles ml-1) showed a linear agreement (r 2 = 0.73) with the other instruments, but individual comparisons at times had large uncertainty. Overall, we found the DIHM and the CCV Pipeline required extensive manual correction, but once corrected, provided concentration and size estimates comparable to the other imaging systems assessed in this study. Holographic cameras are mechanically simple, autonomous, can operate at very high pressures, and provide a larger sampling volume than comparable lens-based tools. Thus, we anticipate that these characterization efforts will be rewarded with novel discovery in new oceanic environments.

Pediatric outpatient utilization by differing Medicaid payment models in the United States.

BACKGROUND: In the United States (US), Medicaid capitated managed care costs are controlled by optimizing patients' healthcare utilization. Adults in capitated plans utilize primary care providers (PCP) more than emergency departments (ED), compared to fee-for-service (FFS). Pediatric data are lacking. We aim to determine the association between US capitated and FFS Medicaid payment models and children's outpatient utilization. METHODS: This retrospective cohort compared outpatient utilization between two payment models of US Medicaid enrollees aged 1-18 years using Truven's 2014 Marketscan Medicaid database. Children enrolled > 11 months were included, and were excluded for eligibility due to disability/complex chronic condition, lack of outpatient utilization, or provider capitation penetration rate < 5% or > 95%. Negative binomial and logistic regression assessed relationships between payment model and number of visits or odds of utilization, respectively. RESULTS: Of 711,008 children, 66,980(9.4%) had FFS and 644,028(90.6%) had capitated plans. Children in capitated plans had greater odds of visits to urgent care, PCP-acute, and PCP-well-child care (aOR 1.21[95%CI 1.15-1.26]; aOR 2.07[95%CI 2.03-2.13]; aOR 1.86 [95%CI 1.82-1.91], respectively), and had lower odds of visits to EDs and specialty care (aOR 0.82 [95%CI 0.8-0.83]; aOR 0.61 [95%CI 0.59-0.62], respectively), compared to FFS. CONCLUSIONS: The majority of children in this US Medicaid population had capitated plans associated with higher utilization of acute care, but increased proportion of lower-cost sites, such as PCP-acute visits and UC. Health insurance programs that encourage capitated payment models and care through the PCP may improve access to timely acute care in lower-cost settings for children with non-complex chronic conditions.

Factors Associated With Urgent Care Reliance and Outpatient Health Care Use Among Children Enrolled in Medicaid.

Importance: Urgent care (UC) centers are a growing option to address children's acute care needs, which may cause unanticipated changes in health care use. Objectives: To identify factors associated with high UC reliance among children enrolled in Medicaid and examine the association between UC reliance and outpatient health care use. Design, Setting, and Participants: A retrospective cohort study used deidentified data on 4 133 238 children from the Marketscan Medicaid multistate claims database to calculate UC reliance and outpatient health care use. Children were younger than 19 years, with 11 months or more of continuous Medicaid enrollment and 1 or more UC, emergency department (ED), primary care provider (PCP; physician, advanced practice nurse, or physician assistant; well-child care [WCC] or non-WCC), or specialist outpatient visit during the 2017 calendar year. Statistical analysis was conducted from November 11 to 26, 2019. Exposures: Urgent care, ED, PCP (WCC and non-WCC), and specialist visits based on coded location of services. Main Outcomes and Measures: Urgent care reliance, calculated by the number of UC visits divided by the sum of total outpatient (UC, ED, PCP, and specialist) visits. High UC reliance was defined as UC visits totaling more than 33% of all outpatient visits. Results: Of 4 133 238 children in the study, 2 090 278 (50.6%) were male, with a median age of 9 years (interquartile range, 4-13 years). A total of 223 239 children (5.4%) had high UC reliance. Children 6 to 12 years of age were more likely to have high UC reliance compared with children 13 to 18 years of age (adjusted odds ratio, 1.07; 95% CI, 1.06-1.09). Compared with white children, black children (adjusted odds ratio, 0.81; 95% CI, 0.81-0.82) and Hispanic children (adjusted odds ratio, 0.61; 95% CI, 0.60-0.61) were less likely to have high UC reliance. Adjusted for age, sex, race/ethnicity, and presence of chronic or complex conditions, children with high UC reliance had significantly fewer PCP encounters (WCC: adjusted rate ratio, 0.60; 95% CI, 0.60-0.61; and non-WCC: adjusted rate ratio, 0.41; 95% CI, 0.41-0.41), specialist encounters (adjusted rate ratio, 0.31; 95% CI, 0.31-0.31), and ED encounters (adjusted rate ratio, 0.68; 95% CI, 0.67-0.68) than children with low UC reliance. Conclusions and Relevance: High UC reliance occurred more often in healthy, nonminority, school-aged children and was associated with lower health care use across other outpatient settings. There may be an opportunity in certain populations to ensure that UC reliance does not disrupt the medical home model.

Actively Doing Less: Deimplementation of Unnecessary Interventions in Bronchiolitis Care Across Urgent Care, Emergency Department, and Inpatient Settings.

BACKGROUND AND OBJECTIVES: Quality improvement (QI) initiatives have increased provider adherence to individual components of a bronchiolitis clinical practice guideline (CPG). Few have evaluated complete adherence to a guideline in multiple types of care settings. Our aim with this study was to increase complete adherence to our institutional bronchiolitis CPG in urgent care center, emergency department, and inpatient settings. METHODS: We conducted a QI study at a single pediatric institution with multiple care settings. Encounters for patients with bronchiolitis ages >60 days to <24 months occurring between October 1 and March 31 in 2015-2018 were included. Those in intensive or subspecialty care were excluded. Management of each encounter was considered adherent to the CPG if none of the following were ordered: respiratory pathogen panel, respiratory syncytial virus antigen, complete blood cell count, blood culture, chest radiography, bronchodilator, antibiotic, or systemic corticosteroid. Medical team education, family engagement, order set modifications, and data dissemination were employed to drive deimplementation. We used interrupted time series to assess changes in processes and outcomes both across and within seasons. RESULTS: Analysis included 13 063 patient encounters. Hospital-wide complete adherence to the CPG increased (P < .001) from 40.9% (95% confidence interval 39.3%-42.5%) to 54.6% (95% confidence interval 53.2%-56.0%). Although CPG adherence improved in all 3 clinical settings, the use of individual CPG components varied by setting. Direct cost decreased in the urgent care center (P < .001) and emergency department (P = .001). CONCLUSIONS: We created a strict definition of CPG adherence and used QI methodology to deimplement multiple overused tests and medications across the continuum of patient care.

Trophic upgrading and mobilization of wax esters in microzooplankton.

Heterotrophic protists play pivotal roles in aquatic ecosystems by transferring matter and energy, including lipids, from primary producers to higher trophic predators. Using Oxyrrhis marina as a model organism, changes to the non-saponifiable protist lipids were investigated under satiation and starvation conditions. During active feeding on the alga Cryptomonas sp., the O. marina hexane soluble non-saponifiable fraction lipid profile reflected its food source with the observed presence of long chain mono-unsaturated fatty alcohols up to C25:1. Evidence of trophic upgrading in O. marina was observed with long chain mono-unsaturated fatty alcohol accumulation of up to C35:1. To the best of our knowledge, this is the first evidence that heterotrophic dinoflagellates are capable of producing ester derived alcohols and that dinoflagellates like O. marina are capable of synthesizing fatty alcohols up to C35. Additionally, we show evidence of trophic upgrading of lipids. During a 20-day resource deprivation, the lipid profile remained constant. During starvation, the mobilization of wax esters as energy stores was observed with long chain fatty alcohols mobilized first. Changes in lipid class profile and utilization of wax esters in O. marina provides insight into the types of lipids available for energy demand, the transfer of lipids through the base of marine food webs, and the catabolic response induced by resource deprivation.

Achievable Benchmarks of Care for Pediatric Readmissions.

BACKGROUND: Most inpatient care for children occurs outside tertiary children's hospitals, yet these facilities often dictate quality metrics. Our objective was to calculate the mean readmission rates and the Achievable Benchmarks of Care (ABCs) for pediatric diagnoses by different hospital types: metropolitan teaching, metropolitan nonteaching, and nonmetropolitan hospitals. METHODS: We used a cross-sectional retrospective study of 30-day, all-cause, same-hospital readmission of patients less than 18 years old using the 2014 Healthcare Utilization Project National Readmission Database. For each hospital type, we calculated the mean readmission rates and corresponding ABCs for the 17 most common readmission diagnoses. We define outlier as any hospital whose readmission rate fell outside the 95% CI for an ABC within their hospital type. RESULTS: We analyzed 690,949 discharges at 525 metropolitan teaching hospitals (550,039 discharges), 552 metropolitan nonteaching hospitals (97,207 discharges), and 587 nonmetropolitan hospitals (43,703 discharges). Variation in readmission rates existed among hospital types; however, sickle cell disease (SCD) had the highest readmission rate and ABC across all hospital types: metropolitan teaching hospitals 15.7% (ABC 7.0%), metropolitan nonteaching 14.7% (ABC 2.6%), and nonmetropolitan 12.8% (ABC not calculated). For diagnoses in which ABCs were available, outliers were prominent in bipolar disorders, major depressive disorders, and SCD. CONCLUSIONS: ABCs based on hospital type may serve as a better metric to explain case-mix variation among different hospital types in pediatric inpatient care. The mean rates and ABCs for SCD and mental health disorders were much higher and with more outlier hospitals, which indicate high-value targets for quality improvement.

Impact of Discharge Components on Readmission Rates for Children Hospitalized with Asthma.

OBJECTIVES: To describe hospital-based asthma-specific discharge components at children's hospitals and determine the association of these discharge components with pediatric asthma readmission rates. STUDY DESIGN: This is a multicenter retrospective cohort study of pediatric asthma hospitalizations in 2015 at children's hospitals participating in the Pediatric Health Information System. Children ages 5 to 17 years were included. An electronic survey assessing 13 asthma-specific discharge components was sent to quality leaders at all 49 hospitals. Correlations of combinations of asthma-specific discharge components and adjusted readmission rates were calculated. RESULTS: The survey response rate was 92% (45 of 49 hospitals). Thirty-day and 3-month adjusted readmission rates varied across hospitals, ranging from 1.9% to 3.9% for 30-day readmissions and 5.7% to 9.1% for 3-month readmissions. No individual or combination discharge components were associated with lower 30-day adjusted readmission rates. The only single-component significantly associated with a lower rate of readmission at 3 months was having comprehensive content of education (P < .029). Increasing intensity of discharge components in bundles was associated with reduced adjusted 3-month readmission rates, but this did not reach statistical significance. This was seen in a 2-discharge component bundle including content of education and communication with the primary medical doctor, as well as a 3-discharge component bundle, which included content of education, medications in-hand, and home-based environmental mitigation. CONCLUSIONS: Children's hospitals demonstrate a range of asthma-specific discharge components. Although we found no significant associations for specific hospital-level discharge components and asthma readmission rates at 30 days, certain combinations of discharge components may support hospitals to reduce healthcare utilization at 3 months.

Urgent Care Utilization in the Pediatric Medicaid Population.

OBJECTIVE: To assess healthcare utilization patterns associated with high (≥3 visits/year) urgent care utilization. STUDY DESIGN: Retrospective analysis of 2 723 792 children who were less than 19 years of age in the 2013 Marketscan Medicaid database. Healthcare utilization categorized as inpatient, emergency department, urgent care, well-child primary care provider (PCP), acute PCP, and specialist visits was documented for 4 groups. We hypothesized that children with high urgent care utilization would have decreased utilization at other sites of care. Multivariable logistic models compared the odds of high urgent care utilization. RESULTS: Of children in the study population, 92.0% had no urgent care visits; 4.7% had 1; 1.5% had 2; and 1.0% had ≥3. Patient attributes of high urgent care utilization were: ages 1-2 years (aOR = 2.32, 95% CI: 2.18-2.36, reference group: 13-18 years), presence of a complex chronic condition (CCC) (aOR = 1.98, 95% CI: 1.88-2.07, reference group: no CCC) and no CCC but ≥3 chronic conditions (aOR = 2.85, 95% CI: 2.73-2.97, reference group: no CCC, no chronic conditions). High urgent care utilization was associated with ≥5 PCP visits for acute care (aOR = 1.16, 95% CI: 1.11-1.20, reference group: 0 visits), and ≥3 emergency department visits (aOR = 2.15, 95% CI: 2.10-2.23, reference group: 0 visits). CONCLUSIONS: Increased urgent care utilization was associated with an increase in overall healthcare utilization. Even though those with higher urgent care utilization had more visits for acute care, patients continued to see their PCP for both well-child and acute care visits.

Racial and Ethnic Differences in Pediatric Readmissions for Common Chronic Conditions.

OBJECTIVE: To compare the timing and magnitude of variation of pediatric readmission rates across race/ethnicity for selected chronic conditions: asthma, diabetes, seizures, migraines, and depression. STUDY DESIGN: Retrospective analysis of hospitalizations at 48 children's hospitals in the 2013 Pediatric Health Information System database for children (ages 0-18 years) admitted for asthma (n = 36 910), seizure (n = 35 361), diabetes (n = 12 468), migraine (n = 5882), and depression (n = 5132). Generalized linear models with a random effect for hospital were used to compare the likelihood of readmission by patients' race/ethnicity, adjusting for severity of illness, age, payer, and medical complexity. Adjusted readmission rates were calculated by week over 1 year. RESULTS: Significant variation in adjusted readmission rates by race/ethnicity existed for conditions aside from depression. Disparities for diabetes and asthma emerged at 3 and 4 weeks, respectively; they remained divergent up to 1 year with the highest 1-year readmission rates in non-Hispanic blacks vs other race/ethnicities (diabetes: 21.7% vs 13.4%, P < .001; asthma: 21.4% vs 14.6%, P < .001). Disparities for migraines and seizure emerged at 6 and 7 weeks, respectively; they remained up to 1 year, with the highest 1-year readmission rates in non-Hispanic whites vs other race/ethnicities (migraine: 17.3% vs 13.6%, P < .001; seizure: 23.9% vs 21.9%, P < .001). CONCLUSIONS: Readmission disparities behave differently across chronic conditions. They emerge more quickly after discharge for children hospitalized with asthma or diabetes than for seizures or migraines. The highest readmission rates were not consistently observed for 1 particular race/ethnicity. Study findings can impact pediatric chronic disease management to improve care for children with these conditions.

pCO2 effects on species composition and growth of an estuarine phytoplankton community.

The effects of ongoing changes in ocean carbonate chemistry on plankton ecology have important implications for food webs and biogeochemical cycling. However, conflicting results have emerged regarding species-specific responses to pCO2 enrichment and thus community responses have been difficult to predict. To assess community level effects (e.g., production) of altered carbonate chemistry, studies are needed that capitalize on the benefits of controlled experiments but also retain features of intact ecosystems that may exacerbate or ameliorate the effects observed in single-species or single cohort experiments. We performed incubations of natural plankton communities from Narragansett Bay, RI, USA in winter at ambient bay temperatures (5-13 °C), light and nutrient concentrations under three levels of controlled and constant CO2 concentrations, simulating past, present and future conditions at mean pCO2 levels of 224, 361, and 724 µatm respectively. Samples for carbonate analysis, chlorophyll a, plankton size-abundance, and plankton species composition were collected daily and phytoplankton growth rates in three different size fractions (<5, 5-20, and >20 µm) were measured at the end of the 7-day incubation period. Community composition changed during the incubation period with major increases in relative diatom abundance, which were similar across pCO2 treatments. At the end of the experiment, 24-hr growth responses to pCO2 levels varied as a function of cell size. The smallest size fraction (<5 µm) grew faster at the elevated pCO2 level. In contrast, the 5-20 µm size fraction grew fastest in the Present treatment and there were no significant differences in growth rate among treatments in the > 20 µm size fraction. Cell size distribution shifted toward smaller cells in both the Past and Future treatments but remained unchanged in the Present treatment. Similarity in Past and Future treatments for cell size distribution and growth rate (5-20 µm size fraction) illustrate non-monotonic effects of increasing pCO2 on ecological indicators and may be related to opposing physiological effects of high CO2 and low pH both within and among species. Interaction of these effects with other factors (e.g., nutrients, light, temperature, grazing, initial species composition) may explain variability among published studies. The absence of clear treatment-specific effects at the community level suggest that extrapolation of species-specific responses or experiments with only present day and future pCO2 treatments levels would produce misleading predictions of ocean acidification impacts on plankton production.