Patterns in hospital admissions for adults with congenital heart disease for non-cardiac procedures.

OBJECTIVE: Advances in management of congenital heart disease (CHD) have led to an increasing population of adults with CHD, many of whom require non-cardiac procedures. The objectives of this study were to describe the characteristics of these patients, their distribution among different hospital categories and the characteristics determining this distribution, and mortality rates following noncardiac procedures. METHODS: We retrospectively analysed 27 state inpatient databases. Encounters with CHD and non-cardiac procedures were included. The location of care was classified into two categories: hospitals with and without cardiac surgical programmes. Variables included were demographics, comorbidity index, mortality. Multivariable logistic regression was used to explore predictors for care in different locations. RESULTS: The cohort consisted of 12 944 encounters in 1206 hospitals. Most patients were cared for in hospitals with a cardiac surgical programme (78.1%). Patients presenting to hospitals with a cardiac surgical programme presented with higher comorbidity index (6 (IQR: 0-19) vs 2 (IQR: -3-14), p<0.001) than patients presenting to hospitals without a cardiac surgical programme. Mortality was higher in hospitals with cardiac surgical programmes compared with hospitals without cardiac surgical programmes (4.0% vs 2.3%, p<0.001). Factors associated with provision of care at a hospital with a cardiac surgical programme were comorbidity index (>7: OR 2.01 (95% CI 1.83 to 2.21), p<0.001; 2-7: OR 1.59 (95% CI 1.41 to 1.79), p<0.001) and age (18-44 years: OR 1.43 (95% CI 1.26 to 1.62), p<0.001; 45-64 years: OR 1.21 (95% CI 1.08 to 1.34), p<0.001). CONCLUSION: Adults with CHD undergoing non-cardiac procedures are mainly cared for in hospitals with a cardiac surgical programme and have greater comorbidities and higher mortality than those in centres without cardiac surgical programmes. Risk stratification and locoregional accessibility need further assessment to fully understand admission patterns.

Hospital Access Patterns of Children With Technology Dependence.

OBJECTIVES: We studied hospital utilization patterns among children with technology dependence (CTD). We hypothesized that increasing pediatric healthcare concentration requires those caring for CTD to selectively navigate healthcare systems and travel greater distances for care. METHODS: Using 2017 all-encounter datasets from 6 US states, we identified CTD visits defined by presence of a tracheostomy, gastrostomy, or intraventricular shunt. We calculated pediatric Hospital Capability Indices for hospitals and mapped distances between patient residence, nearest hospital, and encounter facility. RESULTS: Thirty-five percent of hospitals never saw CTD. Of 37 108 CTD encounters within the remaining 543 hospitals, most emergency visits (70.0%) and inpatient admissions (85.3%) occurred within 34 (6.3%) high capability centers. Only 11.7% of visits were to the closest facility, as CTD traveled almost 4 times further to receive care. When CTD bypassed nearer facilities, they were 10 times more likely to travel to high-capability centers (95% confidence interval: 9.43-10.8), but even those accessing low-capability facilities bypassed less capable, geographically closer hospitals. Transfer was more likely in nearest and low-capability facility encounters. CTD with Medicaid insurance, Black race, or from lower socioeconomic communities had lower odds of encounters at high-capability centers and of bypassing a closer institution than those with white race, private insurance, or from advantaged communities. CONCLUSIONS: Children with technology dependence routinely bypass closer hospitals to access care in facilities with higher pediatric capability. This access behavior leaves many hospitals unfamiliar with CTD, which results in greater travel but less transfers and may be influenced by sociodemographic factors.

Neighborhood Poverty and Distance to Pediatric Hospital Care.

OBJECTIVE: To describe the relationship between neighborhood poverty and geographic access to pediatric inpatient care. METHODS: This is a retrospective, cross-sectional study using 2017-18 hospital and demographic data, as well as geographic data from the 2010 census. Acute care hospitals in 17 states were included, comprising approximately one-third of the national population. The main outcome was distance to capable pediatric hospital care by neighborhood Area Deprivation Index (ADI), both overall and by urbanicity. RESULTS: Median distance to pediatric hospital care increased linearly with poverty across ADI national deciles (Pearson coefficient of 0.986; P < .001). The most advantaged neighborhoods were a median of 2.5 miles from the nearest pediatric capable hospital (interquartile range [IQR] 1.2-5.6) while those in the most disadvantaged were a median of 13.8 miles away (IQR 3.3-35.9; P < .001). The nearest hospital admitted children in 51.17% (7927) of advantaged neighborhoods (lowest national ADI quintile) and only 26.02% (3729) of disadvantaged neighborhoods (highest national ADI quintile). The association between poverty and median distance to care was observed in rural, suburban, and urban census block groups (P < .001 for all trends). In suburban neighborhoods, children from the most disadvantaged neighborhoods were 3 times as likely as children from the most advantaged neighborhoods to live more than 20 miles from pediatric inpatient care (27.85%, 456,533 of children from bottom quintile neighborhoods vs 9.24%, 259,787 of children from top quintile neighborhoods, P < .001). CONCLUSIONS: Distances to capable pediatric hospital care are greater from poor than affluent neighborhoods. This carries potential implications for disparities in pediatric health outcomes.

Patients With Congenital Heart Disease Undergoing Noncardiac Procedures at Hospitals With and Without a Cardiac Surgical Program.

Background The type and location of hospitals where patients with congenital heart disease (CHD) undergo noncardiac procedures have not been investigated. This study aimed to describe (1) the characteristics of these patients, (2) the distribution of procedures among hospitals with and without a cardiac surgical program and travel distances, (3) the characteristics determining the distribution, and (4) mortality rates. Methods and Results This is a retrospective cohort analysis of inpatient data from the Center for Healthcare Information and Analysis of the Commonwealth of Massachusetts, Texas Healthcare Information Collection, and Health Care Cost and Utilization Project State Inpatient Database. Children <18 years old with CHD who underwent noncardiac procedures were included. Distances were calculated using the Haversine formula. Logistic regression was performed to evaluate the odds of a procedure at a hospital with a cardiac program. There were 7435 encounters at 235 hospitals analyzed. Most procedures (87.8%) occurred at hospitals with a cardiac program. Patients at a hospital without a cardiac program had simple CHD (72.4%) with <1% with single ventricle disease. At hospitals with a cardiac program, 56.8% had simple CHD, 35.4% complex CHD, and 7.8% single ventricle disease. The median distance traveled was 25.2 miles (interquartile range, 10.3-73.8 miles) to a hospital with a cardiac program and 14.6 miles (interquartile range, 6.2-37.4 miles) to a hospital without a cardiac program (P<0.001). Single ventricle disease (adjusted odds ratio [aOR], 16.25 [95% CI, 7.22-36.61]) and ≥6 chronic conditions (aOR, 1.81 [95% CI, 1.57-2.09]) were associated with performance at a hospital with a cardiac program. Mortality rate was 3.8%. Conclusions Patients with CHD are more likely to travel to a hospital with a cardiac program for noncardiac procedures than to a hospital without; especially patients with single ventricle disease, other complex CHD, and with ≥6 chronic conditions.

Impact of Allocation on Survival During Intermittent Chemotherapy Shortages: A Modeling Analysis.

BACKGROUND: Intermittent shortages of chemotherapeutics used to treat curable malignancies are a worldwide problem that increases patient mortality. Although multiple strategies have been proposed for managing these shortages (eg, prioritizing patients by age, scarce treatment efficacy per volume, alternative treatment efficacy difference), critical clinical dilemmas arise when selecting a management strategy and understanding its impact. PATIENTS AND METHODS: We developed a model to compare the impact of different allocation strategies on overall survival during intermittent chemotherapy shortages and tested it using vincristine, which was recently scarce for 9 months in the United States. Demographic and treatment data were abstracted from 1,689 previously treated patients in our tertiary-care system; alternatives were abstracted from NCCN Clinical Practice Guidelines in Oncology for each disease and survival probabilities from the studies cited therein. Modeled survival was validated using SEER data. Nine-month shortages were modeled for all possible supply levels. Pairwise differences in 3-year survival and risk reductions were calculated for each strategy compared with standard practice (first-come, first-served) for each 50-mg supply increment, as were supply thresholds above which each strategy maintained survival similar to scenarios without shortages. RESULTS: A strategy prioritizing by higher vincristine efficacy per volume and greater alternative treatment efficacy difference performed best, improving survival significantly (P<.01) across 86.5% of possible shortages (relative risk reduction, 8.3%; 99% CI, 8.0-8.5) compared with standard practice. This strategy also maintained survival rates similar to a model without shortages until supply fell below 72.2% of the amount required to treat all patients, compared with 94.3% for standard practice. CONCLUSIONS: During modeled vincristine shortages, prioritizing patients by higher efficacy per volume and alternative treatment efficacy difference significantly improved survival over standard practice. This approach can help optimize allocation as intermittent chemotherapy shortages continue to arise.

Supraventricular Tachycardia in Infants With Congenital Diaphragmatic Hernia: Prevalence, Associations, and Outcomes.

OBJECTIVES: To characterize the prevalence, associations, management, and outcomes of supraventricular tachycardia (SVT) in neonates with congenital diaphragmatic hernia (CDH). DESIGN: Retrospective chart and cardiology code review within a cohort of patients with CDH was used to define a subpopulation with atrial arrhythmia. SVT mechanisms were confirmed by electrocardiogram analysis. Cox proportional hazard regression identified risk factors for SVT and association with clinical outcomes. SETTING: Medical Surgical ICU in a single, tertiary center, Boston Children's Hospital. PATIENTS: Eligible patients included neonates presenting with classic Bochdalek posterolateral CDH between 2005 and 2017, excluding newborns with Morgagni hernia or late diagnoses of CDH (>28 d). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: SVT arose in 25 of 232 neonates with CDH, (11%); 14 of 25 infants (56%) had recurrent SVT; atrioventricular node-dependent tachycardia was the most frequent mechanism (32%). The majority (71%) of SVT episodes received intervention. Nine patients (36%) received preventative antiarrhythmic medications. SVT was associated with lower Apgar score at 1 min, structural heart disease, larger defect size, extracorporeal membrane oxygenation (ECMO) support, and prostaglandin therapy for ductal patency as well as hospital stay greater than or equal to 8 weeks and use of supplemental oxygen at discharge. CONCLUSIONS: SVT can occur in neonates with CDH and frequently requires treatment. Odds of occurrence are increased with greater CDH disease severity, ECMO, and prostaglandin use. In unadjusted logistic regression analysis, SVT was associated with adverse hospital outcomes, underscoring the importance of recognition and management in this vulnerable population.

Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma.

OBJECTIVE: To describe the current system of pediatric asthma care and identify potential options for unloading tertiary centers. METHODS: Retrospective, cross-sectional study using 2014 inpatient and emergency department all-encounter administrative datasets from Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. Study participants included children <18 with primary diagnosis of asthma. RESULTS: There were 174,239 encounters for pediatric asthma, with 26,316 admissions and 3101 transfers. About 94.4% of transfers were admitted, with median stay length 2 days (interquartile range [IQR] 1.0-3.0). About 637 hospitals saw pediatric asthma, but 58.7% never admitted these patients. Fifty-four hospitals (8.5%) regularly received transfers; these hospitals were broadly capable pediatric centers (mean pediatric hospital capability indices = 0.82, IQR: 0.64-0.89). Two hundred nine facilities (32.8%) did not regularly receive transfers but were highly capable of caring for pediatric asthma (mean condition-specific capability = 0.92, IQR: 0.85-1.00). Median distance from transferring hospitals to the nearest pediatric center was 25.7 miles (IQR: 6.45-50.15) vs 18.0 miles (IQR: 8.35-29.25) to the nearest potential receiving hospital. Mean cost of a 2-day asthma admission in receiving hospitals was $3927 (IQR: $3083-$4894) versus $3427 (IQR: $2485-$4102) in potential receivers. CONCLUSIONS: While nearly all acute care hospitals encounter children with asthma, more than half never admit them. Children are primarily transferred to a small subset of specialized centers, despite the existence, in many regions, of closer community hospitals with high pediatric asthma capability. In settings with long transfer distances and tertiary center crowding, a tiered system of hospital care for pediatric asthma may be feasible.

Socioeconomic Disadvantage and Distance to Pediatric Critical Care.

OBJECTIVES: To describe the geography of pediatric critical care services and the relationship between poverty and distance to these services across the United States. DESIGN: Retrospective, cross-sectional study. SETTING: Contiguous United States. PATIENTS: Children less than 18 years as represented in the 2016 American Community Survey. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Pediatric critical care services were geographically concentrated within urban areas, with half of all PICUs located within 9.5 miles of another (interquartile range, 3.4-51.5 miles). Median distances from neighborhoods to the nearest unit increased linearly with Area Deprivation Index (p < 0.001), such that the median distance from the least privileged neighborhoods was nearly three times that of the most privileged neighborhoods (first decile = 7.8 miles [interquartile range, 3.4-15.8 miles] vs tenth decile = 22.6 miles [interquartile range, 4.2-52.5 miles]; p < 0.001). A relationship between neighborhood poverty and distance to a PICU was present across all U.S. regions and within urban/suburban and rural areas. CONCLUSIONS: In the United States, the distance to pediatric critical care services increases with poverty. This carries implications for access to care and health outcome disparities.

Availability of Inpatient Pediatric Surgery in the United States.

BACKGROUND: In 2015, the American College of Surgeons began its Children's Surgery Verification Quality Improvement Program, promulgating standards intended to promote regionalization and improve pediatric surgical care. It was hypothesized that pediatric surgical care was already highly regionalized and concentrated before implementation of the program. This study aimed to demonstrate this by describing the sites and volume of nonambulatory pediatric surgery. METHODS: A two-part, retrospective, cross-sectional analysis was performed. First, six all-encounter state inpatient data sets (Arkansas, Florida, Kentucky, Maryland, and New York from the Healthcare Cost and Utilization Project and Massachusetts from the Center for Health Information) were used to evaluate all procedures performed within specific hospitals in 2014. Next, a national sample data set (2016 Kids' Inpatient Database) was used to determine the generalizability of the single state results. All acute care hospital admissions for patients less than 18 yr of age were included to describe the nature and location of all surgical procedures therein by patient age, surgical specialty, procedure type, and hospital service breadth. RESULTS: Within the six study states, there were 713 hospitals, of which 635 (89.1%) admitted patients less than 18 yr old, and 516 (72.4%) reported pediatric procedures. Among these, there were 9 specialty hospitals and 39 hospitals with services comparable to independent children's hospitals. Of 153,587 procedures among 1,065,655 pediatric admissions, 127,869 (83.3%) took place within these 48 centers. This fraction decreased with age (89.9% of patients less than 2 yr old and 68.5% of 15- to 17-yr-olds), varied slightly by specialty, and was similar across states. Outside of specialized centers, teenagers accounted for 47.4% of all procedures. Within the national data sample, the concentration was similar: 8.7% (328 of 3,777) of all hospitals admitting children were responsible for 90.1% (793,905 of 881,049) of all procedures, with little regional variation. CONCLUSIONS: Before the American College of Surgeons Children's Surgery Verification Quality Improvement Program, the vast majority of pediatric nonambulatory surgeries were already confined to a small subset of high-capability and specialty centers.

Trends in the Use of Noninvasive and Invasive Ventilation for Severe Asthma.

OBJECTIVES: To explore and define contemporary trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in the treatment of children with asthma. METHODS: We performed a serial cross-sectional analysis using data from the Pediatric Health Information System. We examined 2014-2018 admission abstracts from patients aged 2 to 17 years who were admitted to member hospitals with a primary diagnosis of asthma. We report temporal trends in IMV use, NIV use, ICU admission, length of stay, and mortality. RESULTS: Over the study period, 48 hospitals reported 95 204 admissions with a primary diagnosis of asthma. Overall, IMV use remained stable at 0.6% between 2014 and 2018 (interquartile range [IQR]: 0.3%-1.1% and 0.2%-1.3%, respectively), whereas NIV use increased from 1.5% (IQR: 0.3%-3.2%) to 2.1% (IQR: 0.3%-5.6%). There was considerable practice variation among centers, with NIV rates more than doubling within the highest quartile of users (from 4.8% [IQR: 2.8%-7.5%] to 13.2% [IQR: 7.4%-15.2%]; P < .02). ICU admission was more common among centers with high NIV use, but centers with high NIV use did not differ from lower-use centers in mortality, IMV use, or overall average length of stay. CONCLUSIONS: The use of IMV is at historic lows, and NIV has replaced it as the primary mechanical support mode for asthma. However, there is considerable variability in NIV use. Increased NIV use was not associated with a change in IMV rates, which remained stable. Higher NIV use was associated with increased ICU admissions. NIV's precise contribution to the cost and quality of care remains to be determined.

Assessment of Acute Hospital Use and Transfers for Management of Pediatric Seizures.

Importance: The availability of pediatric hospital care for common conditions is decreasing across the US. The consequences of this decrease on access to care for specific conditions need to be evaluated. Objective: To evaluate the degree of regionalization of pediatric seizure care in the US by characterizing the activity of hospital systems in 6 diverse states. Design, Setting, and Participants: This retrospective cross-sectional study used inpatient and emergency department administrative data sets from all acute care hospitals in Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York from 2014. All patients younger than 18 years who visited a hospital and had a primary diagnosis of seizures were included. Data were analyzed between January and June 2019. Main Outcomes and Measures: Characteristics of hospital encounters and pediatric Hospital Capability Index scores of transferring and admitting hospitals. Results: Among 57 930 encounters with pediatric patients with seizures (median [range] age, 4 [1-11] years; 31 968 [55.2%] boys) identified in 621 acute care hospitals, 15 467 patients (26.7%) were admitted as inpatients and 3748 patients (6.5%) were transferred between acute care hospitals. Among encounters that resulted in transfers between hospitals, seizure was the only diagnosis in 1554 patients (41.5%). A total of 42 463 encounters began as emergency department visits, of which 38 173 encounters (90.0%) resulted in routine discharge. While 536 hospitals (86.3%) transferred children with seizures, only 232 hospitals (37.4%) ever admitted them and only 63 hospitals (10.1%) ever received a pediatric seizure transfer. The median (interquartile range) pediatric Hospital Capability Index score of all hospitals was 0.10 (0.02-0.28), while that of hospitals occasionally admitting pediatric seizure patients was 0.34 (0.22-0.55). However, although most patients who were admitted had brief stays (ie, ≤2 days) and no comorbidities, three-quarters of all admissions (12 002 admissions [77.6%]) were to very highly capable centers (ie, hospitals with pediatric Hospital Capability Index scores >0.75). Across all states, the number of referral hospitals for pediatric seizures was less than the number of Dartmouth Atlas Hospital Referral Regions (47 referral hospitals vs 63 hospital referral regions). Conclusions and Relevance: These findings suggest that although children with seizures are seen in almost all acute care hospital emergency departments, most hospitals transfer children who require admission. Condition-specific interhospital dependency challenges standard definitions of network adequacy and should be accounted for in emergency medical service planning, access to care policies, and health services research.

Visualizing Patterns in Pediatric and Adult Hospital Care.

OBJECTIVES: We aimed to design a graphical tool for understanding and effectively communicating the complex differences between pediatric and adult hospital care systems. PATIENTS AND METHODS: We analyzed the most recent hospital administrative data sets for inpatient admission and emergency department visits from 7 US states (2014: Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York; 2011: California). Probabilities of care completion (Pcc) were calculated for pediatric (<18 years old) and adult conditions in all acute-care hospitals in each state. Using the Pcc, we constructed interactive heatmap visualizations for direct comparison of pediatric and adult hospital care systems. RESULTS: On average, across the 7 states, 70.6% of all hospitals had Pcc >0.5 for more than half of all adult conditions, whereas <14.9% of hospitals had Pcc >0.1 for half of pediatric conditions. Visualizations revealed wide variation among states with clearly apparent institutional dependencies and condition-specific gaps (full interactive versions are available at https://goo.gl/5t8vAw). CONCLUSIONS: The functional disparities between pediatric and adult hospital care systems are substantial, and condition-specific differences should be considered in reimbursement strategies, disaster planning, network adequacy determinations, and public health planning.

Pediatric Specialty Care Model for Management of Chronic Respiratory Failure: Cost and Savings Implications and Misalignment With Payment Models.

OBJECTIVE: To describe program design, costs, and savings implications of a critical care-based care coordination model for medically complex children with chronic respiratory failure. DESIGN: All program activities and resultant clinical outcomes were tracked over 4 years using an adapted version of the Care Coordination Measurement Tool. Patient characteristics, program activity, and acute care resource utilization were prospectively documented in the adapted version of the Care Coordination Measurement Tool and retrospectively cross-validated with hospital billing data. Impact on total costs of care was then estimated based on program outcomes and nationally representative administrative data. SETTING: Tertiary children's hospital. SUBJECTS: Critical Care, Anesthesia, Perioperative Extension and Home Ventilation Program enrollees. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The program provided care for 346 patients and families over the study period. Median age at enrollment was 6 years with more than half deriving secondary respiratory failure from a primary neuromuscular disease. There were 11,960 encounters over the study period, including 1,202 home visits, 673 clinic visits, and 4,970 telephone or telemedicine encounters. Half (n = 5,853) of all encounters involved a physician and 45% included at least one care coordination activity. Overall, we estimated that program interventions were responsible for averting 556 emergency department visits and 107 hospitalizations. Conservative monetization of these alone accounted for annual savings of $1.2-2 million or $407/pt/mo net of program costs. CONCLUSIONS: Innovative models, such as extension of critical care services, for high-risk, high-cost patients can result in immediate cost savings. Evaluation of financial implications of comprehensive care for high-risk patients is necessary to complement clinical and patient-centered outcomes for alternative care models. When year-to-year cost variability is high and cost persistence is low, these savings can be estimated from documentation within care coordination management tools. Means of financial sustainability, scalability, and equal access of such care models need to be established.

Frequency, trends, and antecedents of severe maternal depression after three million U.S. births.

BACKGROUND: Postpartum depression carries adverse consequences for mothers and children, so widespread screening during primary care visits is recommended. However, the rates, timing, and factors associated with significant depressive episodes are incompletely understood. METHODS AND FINDINGS: We examined the Healthcare Cost and Utilization Project (HCUP) State Inpatient, Emergency Department, and Ambulatory Surgery and Services Databases from California (2005-2011) and Florida (2005-2012). Within 203 million records, we identified 3,213,111 births and all mothers who had hospital encounters for severe depression within 40 weeks following delivery. We identified 15,806 episodes of postpartum depression after 11,103 deliveries among 10,883 unique women, and calculated an overall rate of 36.7 depression- associated hospital visits per 10,000 deliveries. Upward trends were observed in both states, with combined five-year increases of 34%. First depressive events were most common within 30 days of delivery, but continued for the entire observation period. About half (1,661/3,325) of PPD first episodes occurred within 34 days of delivery, 70% (2,329/3,325) by the end of the second month, and 87% (2,893/3,325) before four-months of the delivery. Women with private insurance were less likely to have hospital encounters for depression than women with public insurance and women with depression were much more likely to have had some kind of hospital encounter at some time during their pregnancies. Rates of depression increased with the number of prenatal hospital encounters in a "dose-dependent" fashion: the rate of depression was 17.2/10,000 for women with no prenatal hospital visits, doubling for women with at least one encounter (34.9/10,000), and increasing 7-fold to 126/10,000 for women with three or more encounters during their pregnancies. CONCLUSIONS: Our findings suggest that (1) hospital encounters for post-partum depression are increasing, (2) screening should begin very early and continue for the first year after delivery, and (3) added attention should be given to women who had hospital encounters during their pregnancies.

Outcomes of Hospital Transfers for Pediatric Abdominal Pain and Appendicitis.

Importance: Hospital care for children is becoming more concentrated, with interhospital transfer occurring more frequently even for common conditions. Condition-specific analysis is required to determine the value, costs, and consequences of this trend. Objectives: To describe the capabilities of transferring and receiving hospitals and to determine how often children transferred after an initial diagnosis of abdominal pain or appendicitis require higher levels of care. Design, Setting, and Participants: Retrospective cohort analysis using the 2 most recent available inpatient and emergency department administrative data sets from all acute care hospitals in California from 2010 to 2011 and Florida, Massachusetts, and New York from 2013 to 2014. Data were analyzed between February and June 2018. All patients younger than 18 years with a primary diagnosis of abdominal pain or appendicitis who underwent an interhospital transfer and whose care could be matched through unique identifiers were included. Main Outcomes and Measures: Outcomes after hospital transfers, classified into encounters with major surgical procedures, imaging diagnostics, and no major procedures. Pediatric Hospital Capability Index of transferring and receiving hospitals. Results: There were 465 143 pediatric hospital encounters for abdominal pain and appendicitis, including 53 517 inpatient admissions and 15 275 transfers. Among them, 4469 could be matched to encounters in receiving hospitals. The median (interquartile range) age of this cohort was 10 (7-14) years, with 54.8% female (2449 patients), 40.9% male (1830 patients), and 4.3% unreported sex (190 patients). The increase in capability at the receiving hospital compared with the transferring hospital was large (median [interquartile range] change in Pediatric Hospital Capability Index score, 0.70 [0.54-0.82]), with 9.2% of hospitals (57) with very high capability (Pediatric Hospital Capability Index score >0.77) receiving 80.8% of the total transfers (3610). Diagnostic imaging was undertaken in the care of 710 transferred patients (15.9%) and invasive procedures were performed in 2421 patients (54.2%), including 2153 appendectomies. No imaging or surgery was required in the care of 1338 transfers (29.9%). Conclusions and Relevance: In this study, interfacility transfers of patients with appendicitis and abdominal pain were concentrated toward high-capability hospitals, and about 30% of patients were released without apparent intervention. These findings suggest an opportunity for improving care and decreasing cost through better interfacility coordination, such as standardized management protocols and telemedicine with high-capability hospitals. Further research is needed to identify similar opportunities among other common conditions.

Trends in Regionalization of Hospital Care for Common Pediatric Conditions.

OBJECTIVES: We have previously observed that hospital care for children is concentrating significantly in Massachusetts. We now extend those observations to include 4 US states and give closer attention to the management patterns of specific clinical conditions. METHODS: We used inpatient and emergency department administrative data sets from California, Florida, Massachusetts, and New York to measure transfer frequency and identify the site of care completion for >252 million hospital encounters from 2006 through 2013. We compared the concentration of pediatric care to adult care by using the Hospital Capability Index for all acute-care hospitals and quantified the regionalization of clinical conditions by using the Regionalization Index. RESULTS: The availability of hospital care was significantly more limited for children than adults in all 4 states (median Hospital Capability Index: 0.19 vs 0.74 in CA, 0.08 vs 0.79 in FL, 0.18 vs 0.69 in MA, and 0.16 vs 0.75 in NY). Between 2006 and 2011, care was concentrated for both adults and children but much more so for children. Although pediatric admissions decreased by 9.3% (from 545 330 to 494 645), interhospital transfers increased by 24.6% (from 64 285 to 80 101). The largest change in transfer rate was among children with common conditions, such as abdominal pain and asthma. CONCLUSIONS: Definitive pediatric hospital care is less available than adult care and is increasingly dependent on referral centers. This should be accounted for in public health plans, disaster preparedness, and determinations of network adequacy.

Chronic respiratory failure: Utilization of a pediatric specialty integrated care program.

OBJECTIVE: Describe utilization and satisfaction in a specialty integrated care program for children with severe, chronic respiratory insufficiency (CRI). SUBJECTS: Enrollees of the Critical Care, Anesthesia, Perioperative Extension (CAPE) and Home Ventilation Program. METHODS: Children with CRI received home visits, care coordination, and "on-demand" 24/7 access to physicians. Program activity and outcomes were recorded for 3 years using an adapted Care Coordination Measurement Tool© version. Parents completed the Consumer Assessment of Healthcare Providers and Systems (CAHPS). Patient characteristics, program activity, clinical outcomes, utilization, and satisfaction were summarized using descriptive statistics. RESULTS: CAPE provided care for 320 patients from 2012 to 2014 with a median of 7 encounters per year. Neuromuscular (n=132, 41%), chronic lung disease (n=37, 12%), and congenital heart disease (n=13, 4%) represented the majority of underlying conditions. Services included 905 home, 504 clinic, and 3633 telephone encounters, of which 43.6% included a care coordination activity. CAHPS (n=102) revealed that 92.1% (n=93) of children had at least one non-urgent (i.e., routine) visit and nearly two-thirds (64.7%, n=66) reported the need for urgent or emergency care. Overall, parents were highly satisfied with CAPE, with a mean satisfaction rating of 9.3 (±1.3) out of 10. Most parents reported that the CAPE team understood the child's (96.0%, n=95) and family's day-to-day life (86.9%, n=86). CONCLUSIONS: When given open access to an intregated care program, children in our highly complex population required a median of 7 encounters per year. We believe that this experience is scalable and may inform other organizations contemplating similar services.

Availability of Definitive Hospital Care for Children.

Importance: Timely and efficient access to hospital care is essential for the health and well-being of children. As insurance networks, accountable care organizations, and alternative payment methods evolve, these new systems of care must continue to serve the needs of children. Objective: To test the hypothesis that the availability of definitive pediatric hospital care is significantly more limited than adult care and is decreasing disproportionately. Design: This study used case mix data during fiscal years 2004 through 2014 to measure transfer frequency and identify the site of care completion for all patients seen in acute care hospitals throughout Massachusetts. Patterns of care among children were then compared with patterns of care among adults. Participants were all patients seen in an emergency department or admitted to a hospital from 2004 through 2014, including more than 34 million encounters. Main Outcomes and Measures: Hospital Capability Index and Regionalization Index for all acute care hospitals and all conditions within the Clinical Classifications Software of the Healthcare Cost and Utilization Project. Results: Over the study period, the Commonwealth of Massachusetts hospital system was composed of 66 acute care hospitals. After excluding newborns and mental health conditions, there were 34 511 312 encounters, with 25 226 014 emergency department visits and 9 285 298 observation or full admissions. From 2004 through 2014, care for adults and children concentrated among hospitals but much more so for pediatric care. The number of children requiring care in more than one hospital increased 36.2% (from 7190 to 9793). The median (interquartile range [IQR]) Hospital Capability Index, reflecting the likelihood of a hospital completing a patient's care without transfer, decreased 10.8% (from 0.74 [IQR, 0.65-0.81] to 0.66 [IQR, 0.53-0.76]) for adult care and 65.0% (0.20 [IQR, 0.05-0.34] to 0.07 [IQR, 0.01-0.23]) for pediatric care. Almost all of the shift was from nonacademic to academic hospitals. The median Regionalization Index, reflecting the degree to which care for specific conditions is regionalized, was very high for pediatric conditions and further increased from 0.79 (IQR, 0.67-0.91) to 0.87 (IQR, 0.80-0.91). Over the same decade, the mean Regionalization Index for adult conditions was low and increased modestly from 0.25 (IQR, 0.14-0.39) to 0.32 (IQR, 0.19-0.46). Among pediatric conditions, more than 75% were highly regionalized in 2014 compared with fewer than 50% in 2004. Conclusions and Relevance: Pediatric hospital care has become increasingly concentrated, and many children with common conditions are now less frequently treated in the community. This finding has significant implications for systemwide capacity management and should be specifically accounted for in public health activities, disaster planning, and determinations of network adequacy.