Laser Epilation as an Adjunct to Standard Care in Reducing Pilonidal Disease Recurrence in Adolescents and Young Adults: A Randomized Clinical Trial.

Importance: Recurrence continues to be a significant challenge in the treatment and management of pilonidal disease. Objective: To compare the effectiveness of laser epilation (LE) as an adjunct to standard care vs standard care alone in preventing recurrence of pilonidal disease in adolescents and young adults. Design, Setting, and Participants: This was a single-institution, randomized clinical trial with 1-year follow-up conducted from September 2017 to September 2022. Patients aged 11 to 21 years with pilonidal disease were recruited from a single tertiary children's hospital. Intervention: LE and standard care (improved hygiene and mechanical or chemical depilation) or standard care alone. Main Outcomes and Measures: The primary outcome was the rate of recurrence of pilonidal disease at 1 year. Secondary outcomes assessed during the 1-year follow-up included disability days, health-related quality of life (HRQOL), health care satisfaction, disease-related attitudes and perceived stigma, and rates of procedures, surgical excisions, and postoperative complications. Results: A total of 302 participants (median [IQR] age, 17 [15-18] years; 157 male [56.1%]) with pilonidal disease were enrolled; 151 participants were randomly assigned to each intervention group. One-year follow-up was available for 96 patients (63.6%) in the LE group and 134 (88.7%) in the standard care group. The proportion of patients who experienced a recurrence within 1 year was significantly lower in the LE treatment arm than in the standard care arm (-23.2%; 95% CI, -33.2 to -13.1; P < .001). Over 1 year, there were no differences between groups in either patient or caregiver disability days, or patient- or caregiver-reported HRQOL, health care satisfaction, or perceived stigma at any time point. The LE group had significantly higher Child Attitude Toward Illness Scores (CATIS) at 6 months (median [IQR], 3.8 [3.4-4.2] vs 3.6 [3.2-4.1]; P = .01). There were no differences between groups in disease-related health care utilization, disease-related procedures, or postoperative complications. Conclusions and Relevance: LE as an adjunct to standard care significantly reduced 1-year recurrence rates of pilonidal disease compared with standard care alone. These results provide further evidence that LE is safe and well tolerated in patients with pilonidal disease. LE should be considered a standard treatment modality for patients with pilonidal disease and should be available as an initial treatment option or adjunct treatment modality for all eligible patients. Trial Registration: ClinicalTrials.gov Identifier: NCT03276065.

Inequities in the Diagnosis of Pediatric Appendicitis in Tertiary Children's Hospitals and the Consequences of Delayed Diagnosis.

INTRODUCTION: Missed diagnosis (MD) of acute appendicitis is associated with increased risk of appendiceal perforation. This study aimed to investigate whether racial/ethnic disparities exist in the diagnosis of pediatric appendicitis by comparing rates of MD versus single-encounter diagnosis (SED) between racial/ethnic groups. METHODS: Patients 0-18 y-old admitted for acute appendicitis from February 2017 to December 2021 were identified in the Pediatric Health Information System (PHIS). International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes for Emergency Department visits within 7 d prior to diagnosis were evaluated to determine whether the encounter represented MD. Generalized mixed models were used to assess the association between MD and patient characteristics. A similar model assessed independent predictors of perforation. RESULTS: 51,164 patients admitted for acute appendicitis were included; 50,239 (98.2%) had SED and 925 (1.8%) had MD. Compared to non-Hispanic White patients, patients of non-Hispanic Black (odds ratio 2.5, 95% confidence interval 2.0-3.1), Hispanic (2.1, 1.8-2.5), and other race/ethnicity (1.6, 1.2-2.1) had higher odds of MD. There was a significant interaction between race/ethnicity and imaging (P < 0.0001). Among patients with imaging, race/ethnicity was not significantly associated with MD. Among patients without imaging, there was an increase in strength of association between race/ethnicity and MD (non-Hispanic Black 3.6, 2.7-4.9; Hispanic 3.3, 2.6-4.1; other 2.0, 1.4-2.8). MD was associated with increased risk of perforation (2.5, 2.2-2.8). CONCLUSIONS: Minority children were more likely to have MD. Future efforts should aim to mitigate the risk of MD, including implementation of algorithms to standardize the workup of abdominal pain to reduce potential consequences of implicit bias.

Practice Patterns in the Operative Management of Pediatric Thyroid Disease Across Surgical Specializations.

BACKGROUND: Multiple surgical specializations are involved in the operative management of pediatric thyroid disease, but current practice patterns remain unknown. The objective of this study was to examine current practice patterns in the operative management of pediatric thyroid disease, specifically comparing practices across different surgical specializations including pediatric surgery, pediatric otolaryngology, general surgery, adult otolaryngology, and endocrine-focused general surgery. METHODS: Children 0-18 years-old undergoing thyroid surgery from 2015 to 2019 were identified using the Healthcare Cost and Utilization Project State Inpatient Databases and State Ambulatory Surgery and Services Databases across 6 states. Surgeon specialization was determined for all included surgeons. Patient and hospital characteristics were compared across surgical specializations. Clinical outcomes including hypocalcemia/hypoparathyroidism, recurrent laryngeal nerve injury, hematoma, and wound infection were assessed. RESULTS: A total of 1241 pediatric thyroidectomies performed by 363 surgeons were included. Procedures were most frequently performed by pediatric surgeons (34.9%). Only 7.2% of procedures were performed by adult general surgeons. There were statistically significant differences in patient age, sociodemographics, surgical indications, and type of procedure performed between specializations (p < 0.05). Endocrine-focused general surgeons had the highest average annual thyroid procedure volume with 78.2 cases/year, and pediatric surgeons and pediatric otolaryngologists had the lowest volumes with 0.7 and 0.6 cases/year, respectively. Overall complication rates were low. CONCLUSIONS: Operative management of pediatric thyroid disease was most frequently performed by pediatric surgery. Pediatric specializations are more likely to operate on low-income, minority children with public insurance and patients with Graves' disease. Overall complications were low. LEVEL OF EVIDENCE: III.

An Accountable Care Organization Maintains Access for Appendicitis During the COVID-19 Pandemic.

INTRODUCTION: It has been reported that pediatric patients experienced a delay in treatment for acute appendicitis during the pandemic, resulting in increased rates of complicated appendicitis. We investigated the association of the COVID-19 pandemic and the incidence and severity of acute appendicitis among pediatric Medicaid patients using a population-based approach. METHODS: The claims database of Partners For Kids, a pediatric Medicaid accountable care organization (ACO) in Ohio, was queried for cases of acute appendicitis from April to August 2017-2020. The monthly rate of acute appendicitis/100,000 covered lives was calculated each year and compared over time. Rates of complicated appendicitis were also compared. Diagnosis code validation for classification as complicated or uncomplicated appendicitis was performed for patients treated at our hospital. RESULTS: During the study period, 465 unique cases of acute appendicitis were identified. Forty percent (186/465) were coded as complicated. No significant difference in the incidence of acute appendicitis cases was observed across the 4 y, either in an overall comparison or in pairwise comparisons (P > 0.15 for all). The proportion of acute appendicitis cases that were coded as complicated did vary significantly over the 4-year study period (P = 0.005); this was due to this proportion being significantly higher in 2018 than in either 2019 (P = 0.005 versus 2018) or 2020 (P = 0.03 versus 2018). CONCLUSIONS: The COVID-19 pandemic was not associated with reduced access to treatment for acute appendicitis among patients in a pediatric Medicaid ACO. This suggests that an ACO may promote continued healthcare access for their covered population during an unexpected crisis.

Association between high deductible health plan coverage and age at pediatric umbilical hernia repair.

Background: High deductible health plans (HDHPs) are associated with the avoidance of both necessary and unnecessary healthcare. Umbilical hernia repair (UHR) is a procedure that is frequently unnecessarily performed in young children, contrary to best practice guidelines. We hypothesized that children with HDHPs, as compared with other types of commercial health plans, are less likely to undergo UHR before 4 years of age but are also more likely to have UHR delayed beyond 5 years of age. Methods: Children aged 0-18 years old residing in metropolitan statistical areas (MSAs) who underwent UHR in 2012-2019 were identified in the IBM Marketscan Commercial Claims and Encounters Database. A quasi-experimental study design using MSA/year-level HDHP prevalence among children as an instrumental variable was employed to account for selection bias in HDHP enrollment. Two-stage least squares regression modeling was used to evaluate the association between HDHP coverage and age at UHR. Results: A total of 8601 children were included (median age 5 years, IQR 3-7). Univariable analysis revealed no differences between the HDHP and non-HDHP groups in the likelihood of UHR being performed before 4 years of age (27.7% vs 28.7%, p=0.37) or after 5 years of age (39.8% vs 38.9%, p=0.52). Geographical region, metropolitan area size, and year were associated with HDHP enrollment. Instrumental variable analysis demonstrated no association between HDHP coverage and undergoing UHR at <4 years of age (p=0.76) or >5 years of age (p=0.87). Conclusions: HDHP coverage is not associated with age at pediatric UHR. Future studies should investigate other means by which UHRs in young children can be avoided.

Association of the Affordable Care Act Medicaid Expansion With Secondary Overtriage among Young Adult Trauma Patients.

BACKGROUND: Previous work has shown that the Affordable Care Act (ACA) Medicaid expansion decreased the uninsured rate and improved some trauma outcomes among young adult trauma patients, but no studies have investigated the impact of ACA Medicaid expansion on secondary overtriage, namely the unnecessary transfer of non-severely injured patients to tertiary trauma centers. METHODS: Statewide hospital inpatient and emergency department discharge data from two Medicaid expansion and one non-expansion state were used to compare changes in insurance coverage and secondary overtriage among trauma patients aged 19-44 y transferred into a level I or II trauma center before (2011-2013) to after (2014-quarter 3, 2015) Medicaid expansion. Difference-in-difference (DD) analyses were used to compare changes overall, by race/ethnicity, and by ZIP code-level median income quartiles. RESULTS: Medicaid expansion was associated with a decrease in the proportion of patients uninsured (DD: -4.3 percentage points; 95% confidence interval (CI): -7.4 to -1.2), an increase in the proportion of patients insured by Medicaid (DD: 8.2; 95% CI: 5.0 to 11.3), but no difference in the proportion of patients who experienced secondary overtriage (DD: -1.5; 95% CI: -4.8 to 1.8). There were no differences by race/ethnicity or community income level in the association of Medicaid expansion with secondary overtriage. CONCLUSIONS: In the first 2 y after ACA Medicaid expansion, insurance coverage increased but secondary overtriage rates were unchanged among young adult trauma patients transferred to level I or II trauma centers.

The December Effect in Pediatric Elective Surgery Utilization: Differences Between Privately and Publicly Insured Children.

OBJECTIVES: The objective of this study was to identify differences in December elective surgery utilization between privately and publicly insured children, given that increases in the prevalence and size of annual deductibles may be driving more families with commercial health insurance to delay elective pediatric surgical procedures until later in the calendar year. STUDY DESIGN: We identified patients aged <18 years who underwent myringotomy, tonsillectomy ± adenoidectomy, tympanoplasty, hydrocelectomy, orchidopexy, distal hypospadias repair, or repair of inguinal, umbilical, or epigastric hernia using the 2012-2019 state inpatient and ambulatory surgery and services databases of 9 states. Log-binomial regression models were used to compare relative probabilities of procedures being performed each month. Linear regression models were used to evaluate temporal trends in the proportions of procedures performed in December. RESULTS: Our study cohort (n = 1 001 728) consisted of 56.7% privately insured and 41.8% publicly insured children. Peak procedure utilization among privately and publicly insured children was in December (10.1%) and June (9.6%), respectively. Privately insured children were 24% (95% CI 22%-26%) more likely to undergo surgery in December (P < .001), with a significant increase seen for 8 of 9 procedures. There was no trend over time in the percentage of procedures performed in December, except for hydrocelectomies, which increased by 0.4 percentage points/year among privately insured children (P = .02). CONCLUSIONS: Privately insured children are >20% more likely than publicly insured children to undergo elective surgery in December. However, despite increases in the prevalence of high deductibles, the proportion of procedures performed in December has not increased over recent years.

Demographic and Clinical Characteristics Associated With the Failure of Nonoperative Management of Uncomplicated Appendicitis in Children: Secondary Analysis of a Nonrandomized Clinical Trial.

Importance: The factors associated with the failure of nonoperative management of appendicitis and the differences in patient-reported outcomes between successful and unsuccessful nonoperative management remain unknown. Objectives: To investigate factors associated with the failure of nonoperative management of appendicitis and compare patient-reported outcomes between patients whose treatment succeeded and those whose treatment failed. Design, Setting, and Participants: This study was a planned subgroup secondary analysis conducted in 10 children's hospitals that included 370 children aged 7 to 17 years with uncomplicated appendicitis enrolled in a prospective, nonrandomized clinical trial between May 1, 2015, and October 31, 2018, with 1-year follow-up comparing nonoperative management with antibiotics vs surgery for uncomplicated appendicitis. Statistical analysis was performed from November 1, 2019, to February 12, 2022. Interventions: Nonoperative management with antibiotics vs surgery. Main Outcomes and Measures: Failure of nonoperative management and patient-reported outcomes. The relative risk (RR) of failure based on sociodemographic and clinical characteristics was calculated. Patient-reported outcomes were compared based on the success or failure of nonoperative management. Results: Of 370 patients (34.6% of 1068 total patients; 229 boys [61.9%]; median age, 12.3 years [IQR, 10.0-14.6 years]) enrolled in the nonoperative group, treatment failure occurred for 125 patients (33.8%) at 1 year, with 53 patients (14.3%) undergoing appendectomy during initial hospitalization and 72 patients (19.5%) experiencing delayed treatment failure after hospital discharge. Higher patient-reported pain at presentation was associated with increased risk of in-hospital treatment failure (RR, 2.1 [95% CI, 1.0-4.4]) but not delayed treatment failure (RR, 1.3 [95% CI, 0.7-2.3]) or overall treatment failure at 1 year (RR, 1.5 [95% CI, 1.0-2.2]). Pain duration greater than 24 hours was associated with decreased risk of delayed treatment failure (RR, 0.3 [95% CI, 0.1-1.0]) but not in-hospital treatment failure (RR, 1.2 [95% CI, 0.5-2.7]) or treatment failure at 1 year (RR, 0.7 [95% CI, 0.4-1.2]). There was no increased risk of treatment failure associated with age, white blood cell count, sex, race, ethnicity, primary language, insurance status, transfer status, symptoms at presentation, or imaging results. Health care satisfaction at 30 days and patient-reported, health-related quality of life at 30 days and 1 year were not different. Satisfaction with the decision was higher with successful nonoperative management at 30 days (28.0 vs 27.0; difference, 1.0 [95% CI, 0.01-2.0]) and 1 year (28.1 vs 27.0; difference, 1.1 [95% CI, 0.2-2.0]). Conclusions and Relevance: This analysis suggests that a higher pain level at presentation was associated with a higher risk of initial failure of nonoperative management and that a longer duration of pain was associated with lower risk of delayed treatment failure. Although satisfaction was high in both groups, satisfaction with the treatment decision was higher among patients with successful nonoperative management at 1 year. Trial Registration: ClinicalTrials.gov Identifier: NCT02271932.

Characteristics associated with caregiver willingness to consider tonsillectomy for a child's obstructive sleep disordered breathing: Findings from a survey of families in an urban primary care network.

OBJECTIVE: Tonsillectomy use is lower among Black children than White children in the U.S. despite their higher prevalence of obstructive sleep disordered breathing (oSDB). We aimed to identify factors associated with parents' willingness to consider tonsillectomy for their child's oSDB and to identify whether parents of Black children are less willing than parents of non-Black children to be willing to consider the procedure. STUDY DESIGN: Prospective cohort study. SETTING: Primary care network of a tertiary children's hospital. METHODS: We surveyed parents/guardians of children aged 2-10 years with oSDB, to assess their knowledge about oSDB and tonsillectomy, perceived severity of their child's oSDB, perceived level of their child's sleep disturbance, perceived risks and benefits of tonsillectomy, stress, trust in their child's primary care physician and physicians in general, and health literacy. We also assessed child clinical and sociodemographic characteristics. Associations between these characteristics and parent/guardian willingness to consider tonsillectomy for their child's oSDB were assessed. RESULTS: Of the 59 parents/guardians included, 90% were mothers and 71% were Black. Only 58% of caregivers of Black children but 85% of caregivers of non-Black children were willing to consider tonsillectomy (p = 0.04). Caregivers with another child who had undergone tonsillectomy and caregivers who perceived their child's sleep to be more disturbed were more often willing to consider tonsillectomy (both p = 0.02). CONCLUSIONS: Parents of Black children are less willing to consider tonsillectomy for their child's oSDB, but this was not explained by any factors assessed in this study. Future studies should evaluate additional factors that may explain this difference and that might be targeted to ensure appropriate and equitable access to tonsillectomy among children with oSDB.

Impact of Medicaid expansion on young adult firearm and motor vehicle crash trauma patients.

BACKGROUND: The Affordable Care Act Medicaid expansion has increased insurance coverage and reduced some disparities in care and outcomes among trauma patients, but its impact on subsets of trauma patients with particular mechanisms of injury are unclear. This study evaluated the association of the Affordable Care Act Medicaid expansion with insurance coverage, trauma care, and outcomes among young adults hospitalized for firearm- or motor vehicle crash-related injuries. MATERIALS AND METHODS: We used statewide hospital discharge data from 5 Medicaid expansion and 5 nonexpansion states to compare changes in insurance coverage and outcomes among firearm and motor vehicle crash trauma patients aged 19-44 from before (2011-2013) to after (2014-2017) Medicaid expansion. We examined difference in differences overall, by race/ethnicity, and by zip-code-level median income quartile. RESULTS: Medicaid expansion was associated with a decrease in the proportion of young adult motor vehicle crash and firearm trauma patients who were uninsured (motor vehicle crash: difference in differences - 12.7 percentage points, P < .001; firearm: difference in differences - 30.7 percentage points, P < .001). Medicaid expansion was also associated with increases in the percentage of patients discharged to any rehabilitation (motor vehicle crash: difference in differences 1.78 percentage points, P = .001; firearm: difference in differences 2.07 percentage points, P = .02) and inpatient rehabilitation (motor vehicle crash: difference in differences 1.21 percentage points, P = .001; firearm: difference in differences 1.58 percentage points, P = .002). Among patients with firearm injuries, Medicaid expansion was associated with a reduction in in-hospital mortality (difference in differences - 1.55 percentage points, P = .002). CONCLUSION: In its first 4 years, the Affordable Care Act Medicaid expansion increased insurance coverage and access to rehabilitation among young adults hospitalized for firearm- or motor vehicle crash-related injuries while reducing inpatient mortality among firearm trauma patients.

Child Opportunity Index and Changes in Pediatric Acute Care Utilization in the COVID-19 Pandemic.

BACKGROUND: Pediatric acute care utilization decreased dramatically during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between the Child Opportunity Index (COI), a multidimensional neighborhood measure of childhood opportunity, and changes in acute care utilization at US pediatric hospitals during the COVID-19 pandemic compared with the previous 3 years. METHODS: This observational study used administrative data across 41 US-based pediatric hospitals. Children aged 0 to 17 years with emergency department (ED) encounters during the study period were included. The COVID-19 pandemic time period (March 15, 2020-March 14, 2021) was the primary exposure. The primary outcome was the relative volume drop in ED encounters and observation/inpatient admissions through the ED by COI quintile. RESULTS: Of 12 138 750 encounters, 3 705 320 (30.5%) were among the very low COI quintile. Overall, there was a 46.8% relative volume reduction in the pandemic period compared with the prepandmic period. This drop in volume occurred disproportionately among the very low COI quintile (51.1%) compared with the very high COI quintile (42.8%). The majority of clinical diagnosis groups demonstrated larger relative volume drops among the very low COI quintile. CONCLUSIONS: Acute care utilization decreased the most among children from very low COI neighborhoods, narrowing previously described acute care utilization disparities. Additional study of patient perspectives on health care needs and access during this period is required to understand these changes.

Sociodemographic Differences in Care Plans and Time to Treatment Among Children Being Considered for Adenotonsillectomy.

OBJECTIVE: To assess sociodemographic differences in care plans and time to evaluation or treatment after otolaryngologic consultation among children with obstructive sleep-disordered breathing (oSDB). STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary children's hospital. METHODS: We included children aged 2 to 9 years with oSDB seen from June to December 2018 as new otolaryngology clinic patients. Logistic regression was used to examine whether sociodemographic factors were associated with having adenotonsillectomy or polysomnography planned at the end of the visit. Kaplan-Meier analyses and Cox proportional hazards models were used to compare times to these events. RESULTS: An overall 1020 children were included, of whom 65% were White and 18% were Black. Approximately 77% were metropolitan residents, 52% were publicly insured, and 88% of caregivers spoke primarily English. Treatment plans included adenotonsillectomy for 62% of patients, polysomnography for 15%, and new medication therapy for 13%. In multivariable analyses, there were no significant differences by child race/ethnicity, metropolitan/nonmetropolitan residence, type of health insurance, or caregiver primary language in the likelihood of having adenotonsillectomy or polysomnography planned. Among children for whom adenotonsillectomy was planned, children from metropolitan areas had greater times to surgery than children from nonmetropolitan areas (hazard ratio, 0.81 [95% CI, 0.66-0.99]; P = .04). This was explained by a difference between Black children from metropolitan areas and White children from nonmetropolitan areas (hazard ratio, 0.65 [95% CI, 0.49-0.86]; P = .003); there were no racial/ethnic differences in time to surgery among metropolitan-residing children (P = .09). CONCLUSIONS: After initial otolaryngology consultation, children with oSDB from metropolitan areas have longer times to adenotonsillectomy than those from nonmetropolitan areas.

Variability in the management of adhesive small bowel obstruction in children.

BACKGROUND: This study assessed inter-hospital variability in operative-vs-nonoperative management of pediatric adhesive small bowel obstruction (ASBO). METHODS: A multi-institutional retrospective study was performed examining patients 1-21 years-of-age presenting with ASBO from 2010 to 2019 utilizing the Pediatric Health Information System. Multivariable mixed-effects logistic regression was performed assessing inter-hospital variability in operative-vs-nonoperative management of ASBO. RESULTS: Among 6410 pediatric ASBO admissions identified at 46 hospitals, 3,239 (50.5%) underwent surgery during that admission. The hospital-specific rate of surgery ranged from 35.3% (95%CI: 28.5-42.6%) to 74.7% (66.3-81.6%) in the unadjusted model (p < 0.001), and from 35.1% (26.3-45.1%) to 73.9% (66.7-79.9%) in the adjusted model (p < 0.001). Factors associated with operative management for ASBO included admission to a surgical service (OR 2.8 [95%CI: 2.4-3.2], p < 0.001), congenital intestinal and/or rotational anomaly (OR 2.5 [2.1-3.1], p < 0.001), diagnostic workup including advanced abdominal imaging (OR 1.7 [1.5-1.9], p < 0.001), non-emergent admission status (OR 1.5 [1.3-1.8], p < 0.001), and increasing number of complex chronic comorbidities (OR 1.3 [1.2-1.4], p < 0.001). Factors associated with nonoperative management for ASBO included increased hospital-specific annual ASBO volume (OR 0.98 [95%CI: 0.97-0.99], p = 0.002), older age (OR 0.97 [0.96-0.98], p < 0.001), public insurance (OR 0.87 [0.78-0.96], p = 0.008), and presence of coinciding non-intestinal congenital anomalies, neurologic/neuromuscular disease, and/or medical technology dependence (OR 0.57 [95%CI: 0.47-0.68], p < 0.001). CONCLUSIONS: Rates of surgical intervention for ASBO vary significantly across tertiary children's hospitals in the United States. The variability was independent of patient and hospital characteristics and is likely due to practice variation. LEVEL OF EVIDENCE: III.

Association of the Affordable Care Act Medicaid Expansion with Trauma Outcomes and Access to Rehabilitation among Young Adults: Findings Overall, by Race and Ethnicity, and Community Income Level.

BACKGROUND: Low-income young adults disproportionately experience traumatic injury and poor trauma outcomes. This study aimed to evaluate the effects of the Affordable Care Act's Medicaid expansion, in its first 4 years, on trauma care and outcomes in young adults, overall and by race, ethnicity, and ZIP code-level median income. STUDY DESIGN: Statewide hospital discharge data from 5 states that did and 5 states that did not implement Medicaid expansion were used to perform difference-in-difference (DD) analyses. Changes in insurance coverage and outcomes from before (2011-2013) to after (2014-2017) Medicaid expansion and open enrollment were examined in trauma patients aged 19 to 44 years. RESULTS: Medicaid expansion was associated with a decrease in the percentage of uninsured patients (DD -16.5 percentage points; 95% CI, -17.1 to -15.9 percentage points). This decrease was larger among Black patients but smaller among Hispanic patients than White patients. It was also larger among patients from lower-income ZIP codes (p < 0.05 for all). Medicaid expansion was associated with an increase in discharge to inpatient rehabilitation (DD 0.6 percentage points; 95% CI, 0.2 to 0.9 percentage points). This increase was larger among patients from the lowest-compared with highest-income ZIP codes (p < 0.05). Medicaid expansion was not associated with changes in in-hospital mortality or readmission or return ED visit rates overall, but was associated with decreased in-hospital mortality among Black patients (DD -0.4 percentage points; 95% CI, -0.8 to -0.1 percentage points). CONCLUSIONS: The Affordable Care Act Medicaid expansion, in its first 4 years, increased insurance coverage and access to rehabilitation among young adult trauma patients. It also reduced the socioeconomic disparity in inpatient rehabilitation access and the disparity in in-hospital mortality between Black and White patients.

Identification of physical abuse-related hospitalizations in young children: Impact of the transition to ICD-10-CM coding.

BACKGROUND: Administrative healthcare databases are frequently used for child physical abuse (CPA)-related research and surveillance. In October 2015, the United States transitioned to the International Classification of Diseases, Clinical Modification-10th Revision (ICD-10-CM) coding regimen. ICD-10-CM expands coding related to CPA, including codes to differentiate suspected from confirmed CPA. OBJECTIVE: This study examined the impact of the transition to ICD-10-CM coding on population-level trends in rates of hospitalizations coded for CPA. PARTICIPANTS AND SETTINGS: Hospitalizations coded as related to CPA in children <5 years-of-age from 2010 to 2017 were identified across 19 Statewide Inpatient Databases. METHODS: Interrupted time series analyses were used to assess the impact of the coding transition on hospitalizations coded for CPA, overall and by child race/ethnicity. RESULTS: Of 9715 hospitalizations coded for CPA, 2797 (29%) occurred after the coding transition, including 51% coded for suspected CPA and 49% coded for confirmed CPA. There was a marginally-significant increase in the trend in CPA-related hospitalization after the coding transition among all children (0.09 per 100,000 children-per-quarter, p = 0.06), a significant increase in the trend among white children (0.15 per 100,000 children-per-quarter, p = 0.01), and no change among Black or Hispanic children. After the coding transition, hospitalizations coded for suspected CPA increased significantly overall (0.10 per 100,000 children-per-quarter, p < 0.001), and in particular among white children (0.12 per 100,000 children-per-quarter, p = 0.01) but not among Black or Hispanic children. CONCLUSIONS: The transition to ICD-10-CM differentially impacted trends in hospitalizations coded for CPA by child race/ethnicity. Further research is necessary to discern the reasons for these discrepancies.

Variability in age at Kasai portoenterostomy for biliary atresia across US children's hospitals.

BACKGROUND/PURPOSE: The purpose of this study was to assess variability in age at Kasai portoenterostomy (KP) in infants with biliary atresia (BA) across children's hospitals in the United States. STUDY DESIGN: A multi-institutional retrospective study was performed examining infants with BA undergoing KP within 6 months of birth from 2016-2019, utilizing the Pediatric Health Information System (PHIS). Multivariable negative binomial mixed effects regression was performed for age at KP, and inter-hospital variability was examined. RESULTS: Across 46 hospitals, 470 infants with BA underwent KP at a median age of 57 days (IQR 42-72), with 212 (45.1%) undergoing KP at ≥60 days of age. There was significant inter-hospital variability in age at KP ranging from 38 days (95% CI: 31d, 47d) to 76 days (95% CI: 63d, 91d) (p<0.0001). Factors associated with later KP were black or African-American race, urgent/emergent admission, and treatment at a hospital in the Pacific-West region. Predictors of earlier KP included later year, history of neonatal comorbidity, and admission to an intensive care service (all p<0.05). CONCLUSION: There is significant variability in the age at KP in infants with BA across children's hospitals in the United States. TYPE OF STUDY: Retrospective study. LEVEL OF EVIDENCE: III.

Effects of the FDA Codeine Safety Investigation on Racial and Geographic Disparities in Opioid Prescribing after Pediatric Tonsillectomy and/or Adenoidectomy.

Objective. Our objective was to examine the impact of the U.S. FDA's 2013 black box warning against codeine on codeine and other opioid prescription filling after pediatric tonsillectomy and/or adenoidectomy (T/A) overall and by child race and provider urbanity/rurality. Methods. Patients ≤ 18 who underwent T/A in 8/2011 to 8/2016 were identified in Ohio Medicaid claims. Interrupted time series analyses were used to evaluate the impact of the FDA warning on codeine or other opioid prescription filling post-T/A. Results. In August 2011, codeine prescription filling was lower among black than white children (P < .001) and among children treated at institutions in metropolitan counties than less populous counties (P < .001). The FDA warning was associated with a 24.0% drop in codeine prescription filling (P < .001) and 5.5% increase in alternative opioid prescription filling (P = .046). At conclusion, there remained geographic but no longer racial disparities in codeine prescribing. Conclusion. Codeine prescribing after pediatric T/A decreased after the FDA's black box warning. However, geographic disparities in codeine prescribing remain.

Impact of ICD-9-CM to ICD-10-CM coding transition on trauma hospitalization trends among young adults in 12 states.

BACKGROUND: We aimed to estimate the impact of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding transition on traumatic injury-related hospitalization trends among young adults across a geographically and demographically diverse group of U.S. states. METHODS: Interrupted time series analyses were conducted using statewide inpatient databases from 12 states and including traumatic injury-related hospitalizations in adults aged 19-44 years in 2011-2017. Segmented regression models were used to estimate the impact of the October 2015 coding transition on external cause of injury (ECOI) completeness (percentage of hospitalizations with a documented ECOI code) and on population-level rates of injury-related hospitalizations by nature, intent, mechanism, and severity of injury. RESULTS: The transition to ICD-10-CM was associated with a drop in ECOI completion in the transition month (- 3.7%; P < .0001), but there was no significant change in the positive trend in ECOI completion from the pre- to post-transition periods. There were significant increases post-transition in the measured rates of hospitalization for traumatic brain injury (TBI), unintentional injury, mild injury (injury severity score (ISS) < 9), and injuries caused by drowning, firearms, machinery, other pedestrian, suffocation, and unspecified mechanism. Conversely, there were significant decreases in October 2015 in the rates of hospitalization for assault, injuries of undetermined intent, injuries of moderate severity (ISS 9-15), and injuries caused by fire/burn, other pedal cyclist, other transportation, natural/environmental, and other specified mechanism. A significant increase in the percentage of hospitalizations classified as resulting from severe injury (ISS > 15) was observed when the general equivalence mapping maximum severity method for converting ICD-10-CM codes to ICD-9-CM codes was used. State-specific results for the outcomes of ECOI completion and TBI-related hospitalization rates are provided in an online supplement. CONCLUSIONS: The U.S. transition from ICD-9-CM to ICD-10-CM coding led to a significant decrease in ECOI completion and several significant changes in measured rates of injury-related hospitalizations by injury intent, mechanism, nature, and severity. The results of this study can inform the design and analysis of future traumatic injury-related health services research studies that use both ICD-9-CM and ICD-10-CM coded data. LEVEL OF EVIDENCE: II (Interrupted Time Series).

Association of hospital and surgeon operative volumes and surgeon pediatric subspecialization with pediatric laparoscopic cholecystectomy outcomes: A population-based cohort study.

BACKGROUND: Most pediatric cholecystectomies are performed by adult general surgeons, but it is unclear whether outcomes differ by surgeon pediatric subspecialization, hospital procedure volume, or surgeon procedure volume. We aimed to determine whether higher hospital or surgeon laparoscopic cholecystectomy (LC) volume or surgeon pediatric subspecialization is associated with better outcomes after LC in children. METHODS: We performed a retrospective cohort study using statewide hospital discharge databases from the states of Florida, Georgia, and Iowa. We included children aged 4-18 years who underwent inpatient or outpatient LC for acute or chronic gallbladder disease in January 2010-August 2015. Propensity score weighting was used to estimate relationships between operative volumes or surgeon pediatric subspecialization and rates of readmission or emergency department (ED) visit within 30 days. RESULTS: A total of 5391 children were included (mean age 15.9 years, 81.6% female). Children operated on by surgeons with high LC volumes in hospitals with high LC volumes were less likely to experience a readmission or ED visit within 30 days (10.8% vs. 13.7%, p = 0.04). Additionally, children operated on by adult general surgeons in hospitals with high LC volumes were less likely to experience a readmission or ED visit within 30 days (10.9% vs. 13.8%, p = 0.03). CONCLUSIONS: Children are less likely to be readmitted to the hospital or present to the ED after laparoscopic cholecystectomy if they receive their care from adult general surgeons at hospitals that frequently perform this procedure in both adults and children. LEVEL OF EVIDENCE: III.