Multisystem Inflammatory Syndrome in Infants <12 months of Age, United States, May 2020-January 2021.

BACKGROUND: Multisystem inflammatory syndrome in children (MIS-C), temporally associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been identified in infants <12 months old. Clinical characteristics and follow-up data of MIS-C in infants have not been well described. We sought to describe the clinical course, laboratory findings, therapeutics and outcomes among infants diagnosed with MIS-C. METHODS: Infants of age <12 months with MIS-C were identified by reports to the CDC's MIS-C national surveillance system. Data were obtained on clinical signs and symptoms, complications, treatment, laboratory and imaging findings, and diagnostic SARS-CoV-2 testing. Jurisdictions that reported 2 or more infants were approached to participate in evaluation of outcomes of MIS-C. RESULTS: Eighty-five infants with MIS-C were identified and 83 (97.6%) tested positive for SARS-CoV-2 infection; median age was 7.7 months. Rash (62.4%), diarrhea (55.3%) and vomiting (55.3%) were the most common signs and symptoms reported. Other clinical findings included hypotension (21.2%), pneumonia (21.2%) and coronary artery dilatation or aneurysm (13.9%). Laboratory abnormalities included elevated C-reactive protein, ferritin, d-dimer and fibrinogen. Twenty-three infants had follow-up data; 3 of the 14 patients who received a follow-up echocardiogram had cardiac abnormalities during or after hospitalization. Nine infants had elevated inflammatory markers up to 98 days postdischarge. One infant (1.2%) died after experiencing multisystem organ failure secondary to MIS-C. CONCLUSIONS: Infants appear to have a milder course of MIS-C than older children with resolution of their illness after hospital discharge. The full clinical picture of MIS-C across the pediatric age spectrum is evolving.

SARS-CoV-2-Associated Deaths Among Persons Aged <21 Years - United States, February 12-July 31, 2020.

Since February 12, 2020, approximately 6.5 million cases of SARS-CoV-2 infection, the cause of coronavirus disease 2019 (COVID-19), and 190,000 SARS-CoV-2-associated deaths have been reported in the United States (1,2). Symptoms associated with SARS-CoV-2 infection are milder in children compared with adults (3). Persons aged <21 years constitute 26% of the U.S. population (4), and this report describes characteristics of U.S. persons in that population who died in association with SARS-CoV-2 infection, as reported by public health jurisdictions. Among 121 SARS-CoV-2-associated deaths reported to CDC among persons aged <21 years in the United States during February 12-July 31, 2020, 63% occurred in males, 10% of decedents were aged <1 year, 20% were aged 1-9 years, 70% were aged 10-20 years, 45% were Hispanic persons, 29% were non-Hispanic Black (Black) persons, and 4% were non-Hispanic American Indian or Alaska Native (AI/AN) persons. Among these 121 decedents, 91 (75%) had an underlying medical condition,* 79 (65%) died after admission to a hospital, and 39 (32%) died at home or in the emergency department (ED).† These data show that nearly three quarters of SARS-CoV-2-associated deaths among infants, children, adolescents, and young adults have occurred in persons aged 10-20 years, with a disproportionate percentage among young adults aged 18-20 years and among Hispanics, Blacks, AI/ANs, and persons with underlying medical conditions. Careful monitoring of SARS-CoV-2 infections, deaths, and other severe outcomes among persons aged <21 years remains particularly important as schools reopen in the United States. Ongoing evaluation of effectiveness of prevention and control strategies will also be important to inform public health guidance for schools and parents and other caregivers.

Analysis of National Rates, Cost, and Sources of Cost Variation in Adult Spinal Deformity.

BACKGROUND: Several studies suggest significant variation in cost for spine surgery, but there has been little research in this area for spinal deformity. OBJECTIVE: To determine the utilization, cost, and factors contributing to cost for spinal deformity surgery. METHODS: The cohort comprised 55 599 adults who underwent spinal deformity fusion in the 2001 to 2013 National Inpatient Sample database. Patient variables included age, gender, insurance, median income of zip code, county population, severity of illness, mortality risk, number of comorbidities, length of stay, elective vs nonelective case. Hospital variables included bed size, wage index, hospital type (rural, urban nonteaching, urban teaching), and geographical region. The outcome was total hospital cost for deformity surgery. Statistics included univariate and multivariate regression analyses. RESULTS: The number of spinal deformity cases increased from 1803 in 2001 (rate: 4.16 per 100 000 adults) to 6728 in 2013 (rate: 13.9 per 100 000). Utilization of interbody fusion devices increased steadily during this time period, while bone morphogenic protein usage peaked in 2010 and declined thereafter. The mean inflation-adjusted case cost rose from $32 671 to $43 433 over the same time period. Multivariate analyses showed the following patient factors were associated with cost: age, race, insurance, severity of illness, length of stay, and elective admission (P < .01). Hospitals in the western United States and those with higher wage indices or smaller bed sizes were significantly more expensive (P < .05). CONCLUSION: The rate of adult spinal deformity surgery and the mean case cost increased from 2001 to 2013, exceeding the rate of inflation. Both patient and hospital factors are important contributors to cost variation for spinal deformity surgery.

Trends in Utilization and Cost of Cervical Spine Surgery Using the National Inpatient Sample Database, 2001 to 2013.

STUDY DESIGN: A retrospective review. OBJECTIVE: The aim of this study was to determine national rates of cervical spine surgery and to examine factors that underlie cost variation. SUMMARY OF BACKGROUND DATA: There has been an increase in the rate and cost of spinal surgery over the past decades, but there is little understanding of the drivers of cost variation at the national level. METHODS: We analyzed 419,830 patients who underwent cervical spine surgery (anterior cervical fusion, posterior cervical fusion, posterior cervical decompression, combined anterior/posterior cervical fusion) for degenerative conditions in the 2001 to 2013 NIS database. We determined the rates of surgery by time and geographic region, and then created univariate and multivariate models to evaluate the effect of these factors on total hospital costs: patient age, gender, race, insurance, income, county of residence, elective versus nonelective case, length of stay, risk of mortality, severity of illness, hospital bed size, wage index, hospital type, and geographic region. RESULTS: The most common type of cervical spine surgery was anterior fusion (80.6% of all surgeries). The national rates of all cervical spine surgery decreased slightly from 2001 to 2013 (75.34 to 72.20 per 100,000 adults), while the mean inflation-adjusted cost increased 64%, from $11,799 to $19,379, during this time period. Multivariate analyses showed that older age, male gender, black/other race, private insurance, greater risk of mortality/severity of illness, and longer length of stay were associated with higher costs. The wage index was positively correlated with cost, and hospitals in the western U.S. were 27% more expensive than those in the Northeast. CONCLUSION: The rate of cervical spine surgery decreased slightly, while the mean case cost increased at a rate double that of inflation from 2001 to 2013. Even after controlling for patient and hospital factors including wage index, there was significant geographic variation in the cost for cervical spine surgery. LEVEL OF EVIDENCE: 3.

Analysis of Cost Variation in Craniotomy for Tumor Using 2 National Databases.

BACKGROUND: There is a significant increase and large variation in craniotomy costs. However, the causes of cost differences in craniotomies remain poorly understood. OBJECTIVE: To examine the patient and hospital factors that underlie the cost variation in tumor craniotomies using 2 national databases: the National Inpatient Sample (NIS) and Vizient, Inc. (Irving, Texas). METHODS: For 41 483 patients who underwent primary surgery for supratentorial brain tumors from 2001 to 2013 in the NIS, we created univariate and multivariate models to evaluate the effect of several patient factors and hospital factors on total hospital cost. Similarly, we performed multivariate analysis with 15 087 cases in the Vizient 2012 to 2015 database. RESULTS: In the NIS, the mean inflation-adjusted cost per tumor craniotomy increased 30%, from $23 021 in 2001 to $29 971 in 2013. In 2001, the highest cost region was the Northeast ($24 486 ± $1184), and by 2013 the western United States was the highest cost region ($36 058 ± $1684). Multivariate analyses with NIS data showed that male gender, white race, private insurance, higher mortality risk, higher severity of illness, longer length of stay, elective admissions, higher wage index, urban teaching hospitals, and hospitals in the western United States were associated with higher tumor craniotomy costs (all P < .05). Multivariate analyses with Vizient data confirmed that longer length of stay and the western United States were significantly associated with higher costs (P < .001). CONCLUSION: After controlling for patient/clinical factors, hospital type, bed size, and wage index, hospitals in the western United States had higher costs than those in other parts of the country, based on analyses from 2 separate national databases.

Geographic and Hospital Variation in Cost of Lumbar Laminectomy and Lumbar Fusion for Degenerative Conditions.

BACKGROUND: Spinal surgery costs vary significantly across hospitals and regions, but there is insufficient understanding of what drives this variation. OBJECTIVE: To examine the factors underlying the cost variation for lumbar laminectomy/discectomy and lumbar fusions. METHODS: We obtained patient information (age, gender, race, severity of illness, risk of mortality, population of county of residence, median zipcode income, insurance status, elective vs nonelective admission, length of stay) and hospital data (region, hospital type, bed size, wage index) for all patients who underwent lumbar laminectomy/discectomy (n = 181 267) or lumbar fusions (n = 433 364) for degenerative conditions in the 2001 to 2013 National Inpatient Sample database. We performed unadjusted and adjusted analyses to determine which factors affect cost. RESULTS: Mean costs for lumbar laminectomy/discectomy and lumbar fusion increased from $8316 and $21 473 in 2001 (in inflation-adjusted 2013 dollars), to $11 405 and $29 438, respectively, in 2013. There was significant regional variation in cost, with the West being the most expensive region across all years and showing the steepest increase in cost over time. After adjusting for patient and hospital factors, the West was 23% more expensive than the Northeast for lumbar laminectomy/discectomy, and 25% more expensive than the Northeast for lumbar fusion ( P < .01). Higher wage index, smaller hospital bed size, and rural/urban nonteaching hospital type were also associated with higher cost for lumbar laminectomy/discectomy and fusion ( P < .01). CONCLUSION: After adjusting for patient factors and wage index, the Western region, hospitals with smaller bed sizes, and rural/urban nonteaching hospitals were associated with higher costs for lumbar laminectomy/discectomy and lumbar fusion.