Long-Term Neurodevelopment of Low-Birthweight, Preterm Infants with Patent Ductus Arteriosus.

OBJECTIVE: To evaluate whether the presence of patent ductus arteriosus (PDA) in preterm infants worsens long-term neurodevelopmental outcomes. STUDY DESIGN: This was a secondary observational analysis of data from 1090 preterm low-birthweight infants in the Infant Health and Development Program (IHDP), a multicenter longitudinal cohort study of outcomes assessed from 3 to 18 years of age. Multivariable analysis was adjusted for IHDP treatment group (intervention or follow-up), birth weight, maternal race, maternal education, infant sex, maternal preconception weight, Home Observation Measurement of the Environment (HOME) total score at 12 months, neonatal health index, and gestational age. RESULTS: Of the 1090 patients (49% male) included in the analysis, 135 had a PDA. Mean birth weight (1322 g vs 1871 g; P < .0001) and gestational age (30.2 weeks vs 33.4 weeks, P < .0001) were lower and mean ventilator days (11.8 vs 1.3; P < .0001), vasopressor use (12.6% vs 1.2%; P < .0001), and congestive heart failure (8.9% vs 0.1%; P < .0001) were higher in the PDA group. There were no differences between the PDA and no-PDA groups in maternal education level and HOME total score at age 12 months. Multivariable analysis demonstrated no between-group differences in cognitive development or behavioral competence at age 3, 8, and 18 years. CONCLUSIONS: The presence of a PDA in moderately preterm, low-birthweight infants does not impact long-term neurodevelopmental outcomes.

Using an Interactive Video Simulator to Improve Certified Nursing Assistants' Dressing Assistance and Nursing Home Residents' Dressing Performance: A Pilot Study.

This pilot study examined the initial effects and estimated effect size of a computer-based simulation education program on certified nursing assistants' level of assistance when dressing nursing home residents with dementia and on residents' dressing performance. Nine dyads, assigned to either the experimental or control group, completed the study. Both groups received a traditional 1-hour education module delivered by a research assistant. The experimental group was then instructed to undertake an additional 2-hour intervention using a video simulator that enabled nursing assistants to practice level of assistance skills. The appropriateness of dressing assistance from nursing assistants and residents' dressing performance was measured before and 6 weeks after the intervention. The results showed that the two groups did not significantly differ in either appropriate levels of dressing assistance (P = .42) or residents' dressing performance (P = .38). A lack of effort by some assistants to properly assist residents and low statistical power may explain the lack of significance. The effect sizes of the experimental intervention on appropriate levels of dressing assistance and resident dressing performance were 0.69 and 0.89, respectively. Incorporating a strategy to improve motivation should be considered in future studies.

Development and Validation of an Empiric Tool to Predict Favorable Neurologic Outcomes Among PICU Patients.

OBJECTIVES: To create a novel tool to predict favorable neurologic outcomes during ICU stay among children with critical illness. DESIGN: Logistic regression models using adaptive lasso methodology were used to identify independent factors associated with favorable neurologic outcomes. A mixed effects logistic regression model was used to create the final prediction model including all predictors selected from the lasso model. Model validation was performed using a 10-fold internal cross-validation approach. SETTING: Virtual Pediatric Systems (VPS, LLC, Los Angeles, CA) database. PATIENTS: Patients less than 18 years old admitted to one of the participating ICUs in the Virtual Pediatric Systems database were included (2009-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 160,570 patients from 90 hospitals qualified for inclusion. Of these, 1,675 patients (1.04%) were associated with a decline in Pediatric Cerebral Performance Category scale by at least 2 between ICU admission and ICU discharge (unfavorable neurologic outcome). The independent factors associated with unfavorable neurologic outcome included higher weight at ICU admission, higher Pediatric Index of Morality-2 score at ICU admission, cardiac arrest, stroke, seizures, head/nonhead trauma, use of conventional mechanical ventilation and high-frequency oscillatory ventilation, prolonged hospital length of ICU stay, and prolonged use of mechanical ventilation. The presence of chromosomal anomaly, cardiac surgery, and utilization of nitric oxide were associated with favorable neurologic outcome. The final online prediction tool can be accessed at https://soipredictiontool.shinyapps.io/GNOScore/. Our model predicted 139,688 patients with favorable neurologic outcomes in an internal validation sample when the observed number of patients with favorable neurologic outcomes was among 139,591 patients. The area under the receiver operating curve for the validation model was 0.90. CONCLUSIONS: This proposed prediction tool encompasses 20 risk factors into one probability to predict favorable neurologic outcome during ICU stay among children with critical illness. Future studies should seek external validation and improved discrimination of this prediction tool.

Relationship of Hospital Costs With Mortality in Pediatric Critical Care: A Multi-Institutional Analysis.

OBJECTIVE: With increasing emphasis on high "value" care, we designed this study to evaluate the relationship between hospital costs and patient outcomes in pediatric critical care. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information Systems. Multivariable mixed effects logistic regression models were fitted to evaluate association of hospital cost tertiles with odds of mortality after adjusting for patient and center characteristics. SETTING: Forty-seven children's hospitals across the United States. PATIENTS: Patients 18 years old or younger admitted to a PICU at a Pediatric Health Information Systems participating hospital were included (2004-2015). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 917,663 patients from 47 hospitals were included. Median cost per patient was $42,181 in the low-cost hospitals (341,689 patients, 16 hospitals), $56,806 in the middle-cost hospitals (310,293 patients, 16 hospitals), and $82,588 in the high-cost hospitals (265,681 patients, 15 hospitals). In unadjusted analysis, patients cared for in the high-cost tertile hospitals were younger in age, associated with more comorbidities, had higher resource utilization (including extracorporeal membrane oxygenation and nitric oxide), had higher prevalence of cardiac arrest, and were associated with worse outcomes (including mortality). In adjusted analysis, high-cost tertile hospitals were not associated with improved mortality, when compared with low- and medium-cost tertile hospitals (low cost vs high cost: odds ratio, 0.99; 95% CI, 0.79-1.25 and middle cost vs high cost: odds ratio, 1.10; 95% CI, 0.86-1.41). When stratified by diagnoses category, we noted similar trends among cardiac and noncardiac patients. CONCLUSIONS: This large observational study did not demonstrate any relationship between hospital costs and patient outcomes in children with critical illness. Further efforts are needed to evaluate quality-cost relationship and high value care in critically ill children across centers of varying volume by linking data from clinical and administrative databases.

Is Administration of Nitric Oxide During Extracorporeal Membrane Oxygenation Associated With Improved Patient Survival?

OBJECTIVE: To evaluate the outcomes associated with the use of inhaled nitric oxide during extracorporeal membrane oxygenation. DESIGN: Post hoc analysis of data from an existing administrative national database, Pediatric Health Information system (2004-2014). Multivariable logistic regression models were fitted to study the effect of inhaled nitric oxide during extracorporeal membrane oxygenation on study outcomes. SETTING: Forty-two children's hospitals across the United States. PATIENTS: Patients in the age group from 1 day through 18 years admitted to an ICU who received extracorporeal membrane oxygenation during their hospital stay were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: In total, 6,419 patients qualified for inclusion. Of these, inhaled nitric oxide was used among 3,629 patients during extracorporeal membrane oxygenation run. Approximately one half of the study patients received inhaled nitric oxide at extracorporeal membrane oxygenation initiation. The proportion of patients receiving inhaled nitric oxide during extracorporeal membrane oxygenation decreased with increasing duration of extracorporeal membrane oxygenation. After adjusting for patient characteristics and center variables, use of inhaled nitric oxide was not associated with any survival benefit. However, higher proportion of patients receiving inhaled nitric oxide were associated with prolonged hospital length of stay and prolonged duration of extracorporeal membrane oxygenation. In adjusted models, the hospital charges were higher in the inhaled nitric oxide group. The median hospital costs among patients receiving inhaled nitric oxide were higher by $39,732 (95% CI, $31,074-48,390) as compared to the patients who did not receive inhaled nitric oxide, after adjusting for patient (including hospital length of stay) and center level variables. As the duration of inhaled nitric oxide therapy increased, proportion of patients with prolonged duration of extracorporeal membrane oxygenation and prolonged hospital length of stay increased. CONCLUSIONS: This large observational analysis of use of nitric oxide during extracorporeal membrane oxygenation calls into question the benefits of inhaled nitric oxide among patients receiving extracorporeal membrane oxygenation for pulmonary or cardiac failure. Given our inability to determine type of extracorporeal membrane oxygenation and control for severity of illness, these findings should be interpreted as exploratory.

Temporal Trends of Respiratory Syncytial Virus-Associated Hospital and ICU Admissions Across the United States.

OBJECTIVES: To describe the regionality and seasonality of respiratory syncytial virus-associated hospital and ICU admissions for 10 consecutive years using a national database. DESIGN: Post hoc analysis of data from an existing national database, Pediatric Health Information System. We modeled the adjusted odds of hospital and ICU admissions for varied seasons (fall, winter, spring, and summer) and regions (Northeast, South, Midwest, and West) using a mixed-effects logistic regression model after adjusting for several patient and center characteristics. SETTING: Forty-two children's hospitals across the Unites States. PATIENTS: Patients 1 day through 24 months old with inpatient admission (ward and/or ICU) for respiratory syncytial virus- associated infection at a Pediatric Health Information System-participating hospital were included (2004-2013). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,937,994 inpatient admissions during the study period, 146,357 children were admitted for respiratory syncytial virus-associated acute respiratory illness. Of these inpatient admissions, 32,470 children(22%) were admitted to ICU during their hospital stay. Overall adjusted odds of respiratory syncytial virus-associated hospital and ICU admissions in recent years (2010-2013) were higher than previous years (2004-2006 and 2007-2009). In recent years, respiratory syncytial virus-associated hospital and ICU admissions have increased in winter and spring seasons. Regionally in recent years, the overall adjusted odds of both respiratory syncytial virus-associated hospital and ICU admissions have increased in the South and West regions. CONCLUSIONS: Wide variations in regional and seasonal patterns in hospital and ICU admissions were noted in children with respiratory syncytial virus-associated acute respiratory illness across the United States. Results from our study help us better understand the seasonality and regionality of respiratory syncytial virus infection in the United States with the goal to decrease the financial impact on our already stressed healthcare system by being better prepared for respiratory syncytial virus season.

Association Between Extracorporeal Membrane Oxygenation Center Volume and Mortality Among Children With Heart Disease: Propensity and Risk Modeling.

OBJECTIVES: To evaluate the relationship between extracorporeal membrane oxygenation center volume and mortality in children undergoing heart operations using propensity score matching in a multiinstitutional cohort. DESIGN: Post hoc analysis of data from an existing national database, Pediatric Health Information System. Propensity score matching was performed to 1-1-1 match patients in low-volume (0-30 cases per year), medium-volume (31-50 cases per year), and high-volume (> 50 cases per year) categories. We tested the sensitivity of our findings by repeating the primary analyses using traditional statistical techniques (traditional regression-based methods and covariate adjustment using propensity score). SETTING: Forty-two children's hospitals across the Unites States. PATIENTS: Patients 18 years old or younger receiving extracorporeal membrane oxygenation before or after pediatric heart operation at a Pediatric Health Information System participating hospital (2004-2013) were included. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 3,502 from 42 hospitals qualified for inclusion. Using propensity score matching, 1,962 patients were matched 1-1-1 to compare the three volume categories (654 patients in each category). Overall mortality was 1,493 patients (43%). Before matching and adjustment, low- and medium-volume centers were associated with higher mortality (low versus high volume: unadjusted odds ratio, 1.99; 95% CI, 1.68-2.36; p < 0.001). After matching, there was no significant association between center volume and mortality in unadjusted and adjusted analyses (low versus high volume: unadjusted odds ratio, 1.06; 95% CI, 0.85-1.32; p = 0.62 and adjusted odds ratio, 0.97; 95% CI, 0.63-1.50; p = 0.90). This relationship remained similar for analyses using traditional statistical techniques (regression adjustment, low versus high volume: adjusted odds ratio, 1.23; 95% CI, 0.80-1.89; p = 0.35 and covariate adjustment using propensity score, low versus high volume: adjusted odds ratio, 1.16; 95% CI, 0.77-1.74; p = 0.49). CONCLUSIONS: We demonstrated no relationship between extracorporeal membrane oxygenation center volume and mortality. Further analyses are needed to evaluate this relationship.