Persistent Opioid Use Following Pediatric Nonfatal Firearm Injury.

OBJECTIVE: Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims. METHODS: We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use. RESULTS: Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use. CONCLUSIONS: Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.

Health Care Utilization After Nonfatal Firearm Injuries.

OBJECTIVES: Despite the high incidence of firearm injuries, little is known about health care utilization after nonfatal childhood firearm injuries. This study aimed to describe health care utilization and costs after a nonfatal firearm injury among Medicaid and commercially insured youth using a propensity score matched analysis. METHODS: We conducted a propensity score matched cohort analysis using 2015 to 2018 Medicaid and Commercial Marketscan data comparing utilization in the 12-months post firearm injury for youth aged 0 to 17. We matched youth with a nonfatal firearm injury 1:1 to comparison noninjured youth on demographic and preindex variables. Outcomes included inpatient hospitalizations, emergency department (ED) visits, and outpatient visits as well as health care costs. Following propensity score matching, regression models estimated relative risks of the health care utilization outcomes, adjusting for demographic and clinical covariates. RESULTS: We identified 2110 youth with nonfatal firearm injury. Compared with matched noninjured youth, firearm injured youth had a 5.31-fold increased risk of inpatient hospitalization (95% confidence interval [CI] 3.93-7.20), 1.49-fold increased risk of ED visit (95% CI 1.37-1.62), and 1.06-fold increased risk of outpatient visit (95% CI 1.03-1.10) 12-months postinjury. Adjusted 12-month postindex costs were $7581 (95% CI $7581-$8092) for injured youth compared with $1990 (95% CI $1862-2127) for comparison noninjured youth. CONCLUSIONS: Youth who suffer nonfatal firearm injury have a significantly increased risk of hospitalizations, ED visits, outpatient visits, and costs in the 12 months after injury when compared with matched youth. Applied to the 11 258 US youth with nonfatal firearm injuries in 2020, estimates represent potential population health care savings of $62.9 million.

Firearm Safety Screening in the Pediatric Hospital Setting: A Quality Improvement Initiative.

Background: Firearm injuries are a leading cause of morbidity and mortality for US youth. Secure storage is protective against firearm injuries in children. Despite this evidence and national recommendations, rates of firearm safety screening among pediatric providers are low, particularly in the inpatient setting. Therefore, we aimed to increase the frequency of firearm safety screening among patients admitted to the Pediatric Hospital Medicine service. Methods: This project occurred in a tertiary pediatric hospital with a medium-sized pediatric residency program. The initial intervention was a firearm safety screening tool embedded into the electronic health record history and physical note template. Subsequent interventions included nursing education, monthly reminder emails, and gun violence discussions during intern orientation. Patients who screened positive were provided with educational materials and a free gun lock. Data collection occurred by chart review to determine the frequency of screening documentation in the H&P. A survey was also conducted among pediatric residents to identify persistent barriers to screening. Results: The percentage of inpatient firearm safety screening increased from 0.01% to 39% over 25 months, with a centerline shift noted after 2 months. Residents cited a lack of time with the patient and a belief that it was not the appropriate time to screen as persistent barriers to screening. Conclusions: This study identified an effective approach to improving firearm safety screening in an academic pediatric hospital. Hospitalization represents a unique opportunity for firearm safety screening and counseling, and inpatient providers should feel empowered to intervene in this setting.

Access to Firearms: Initiation of Firearm Screening Among Psychiatric Patients in a Pediatric Emergency Department.

OBJECTIVE: Increase provider screening rates for firearm access among patients presenting to the pediatric emergency department (PED) for a psychiatric chief complaint. METHODS: In this resident-driven quality improvement project, a retrospective chart review examined firearm access screening rates among patients presenting to the PED with the chief complaint of "psychiatric evaluation." After establishing our baseline screening rate, the first phase of our plan, do, study, act (PDSA) cycle included implementing Be SMART education for pediatric residents. We made Be SMART handouts available in the PED, created electronic medical record (EMR) templates to facilitate documentation, and emailed routine reminders to residents during their PED block. In the second PDSA cycle, the pediatric emergency medicine (PEM) fellows expanded our efforts to increase project awareness from a supervisory role. RESULTS: The baseline screening rate was 14.7% (50 of 340). After PDSA 1, a center line shift occurred, and screening rates increased to 34.3% (297 of 867). After PDSA 2, screening rates increased to 35.7% (226 of 632). In the intervention phase, providers who received training screened 39.5% (238 of 603) of encounters versus providers who did not receive training screened 30.8% (276 of 896) of encounters. Of all encounters screened, 39.2% (205 of 523) screened positive for in-home firearms. CONCLUSIONS: We improved firearm access screening rates in the PED using provider education, EMR prompts, and PEM fellow participation. Opportunities remain to promote firearm access screening and secure storage counseling in the PED.

Mental Health Care Utilization Among Children and Adolescents With a Firearm Injury.

Importance: Firearm injuries are a leading cause of morbidity and mortality among US children and adolescents. Despite evidence demonstrating mental health sequelae for children and adolescents who have experienced a firearm injury, little is known about mental health care utilization after a firearm injury. Objective: To evaluate mental health care utilization in the 12 months after a firearm injury among Medicaid-insured and commercially insured children and adolescents compared with propensity score-matched controls. Design, Setting, and Participants: This propensity score-matched retrospective cohort analysis assessed 2127 children and adolescents, aged 0 to 17 years, with a firearm injury that occurred between January 1, 2016, and December 31, 2017, compared with 2127 matched controls using MarketScan Medicaid and commercial claims data. Claims data were analyzed 12 months before and after injury, with the total study period spanning from January 1, 2015, to December 31, 2018. Exposure: Nonfatal firearm injury. Main Outcomes and Measures: The primary outcome of interest was a dichotomous variable representing any mental health care utilization in the 12 months after injury. Secondary outcomes included psychotherapy utilization, substance use-related utilization, and a psychotropic medication prescription. Logistic regression modeling was used to estimate relative risks with adjusted analyses of dichotomous outcomes. Results: The overall cohort consisted of 4254 children and adolescents, of whom 2127 (mean [SD] age, 13.5 [4.1] years; 1722 [81.0%] male) had an initial encounter for a firearm injury and an equal number of matched controls (mean [SD] age, 13.5 [4.1] years; 1720 [80.9%] male). Children and adolescents with a firearm injury had a 1.40 times greater risk (95% CI, 1.25-1.56; P < .001) of utilizing mental health services in the 12 months after their injury compared with children and adolescents without a firearm injury, after controlling for potential confounders. Children and adolescents with a firearm injury had a 1.23 times greater risk (95% CI, 1.06-1.43; P = .007) of utilizing psychotherapy and a 1.40 times greater risk (95% CI, 1.19-1.64; P < .001) of substance use-related utilization. Among those who experienced a firearm injury, Black children and adolescents were 1.64 times more likely (95% CI, 1.23-2.19; P < .001) to utilize mental health care compared with White children and adolescents. Conclusions and Relevance: This propensity score-matched cohort study found that children and adolescents with a firearm injury had a greater risk of utilizing mental health services in the 12 months after their injury compared with those without an injury, and significant racial disparities were associated with use of mental health services. The findings suggest that health care practitioners should be aware of this increased risk and ensure adequate mental health follow-up for these patients.

Mental Health Care Following Firearm and Motor Vehicle-related Injuries: Differences Impacting Our Treatment Strategies.

OBJECTIVE: To compare new mental health diagnoses (NMHD) in children after a firearm injury versus following a motor vehicle collision (MVC). BACKGROUND: A knowledge gap exists regarding childhood mental health diagnoses following firearm injuries, notably in comparison to other forms of traumatic injury. METHODS: We utilized Medicaid MarketScan claims (2010-2016) to conduct a matched case-control study of children ages 3 to 17 years. Children with firearm injuries were matched with up to 3 children with MVC injuries. Severity was determined by injury severity score and emergency department disposition. We used multivariable logistic regression to measure the association of acquiring a NMHD diagnosis in the year postinjury after firearm and MVC mechanisms. RESULTS: We matched 1450 children with firearm injuries to 3691 children with MVC injuries. Compared to MVC injuries, children with firearm injuries were more likely to be black, have higher injury severity score, and receive hospital admission from the emergency department ( P <0.001). The adjusted odds ratio (aOR) of NMHD diagnosis was 1.55 [95% confidence interval (95% CI): 1.33-1.80] greater after firearm injuries compared to MVC injuries. The odds of a NMHD were higher among children admitted to the hospital compared to those discharged. The increased odds of NMHD after firearm injuries was driven by increases in substance-related and addictive disorders (aOR: 2.08; 95% CI: 1.63-2.64) and trauma and stressor-related disorders (aOR: 2.07; 95% CI: 1.55-2.76). CONCLUSIONS: Children were found to have 50% increased odds of having a NMHD in the year following a firearm injury as compared to MVC. Programmatic interventions are needed to address children's mental health following firearm injuries.

Adolescent Suicide-Understanding Unique Risks and Opportunities for Trauma Centers to Recognize, Intervene, and Prevent a Leading Cause of Death.

Purpose of Review: This provides up-to-date epidemiology of adolescent suicide and risk factors for suicide and highlights the overlap of risks for suicide and injury. It reviews signs and symptoms, and the up-to-date evidence on screening for depression, post-traumatic stress disorder (PTSD), suicide, substance abuse, and lethal means, and offers strategies of implementation in trauma centers. Recent Findings: The incidence of adolescent suicide has continued to rise in the USA to 6.5 per 100,000, with notable racial disparities. The risk factors are complex, but many pre-existing risk factors and sequela after injury such as exposures to violence, suicidal behaviors, substance abuse, depression and post-traumatic stress disorder, and specific injuries including traumatic brain injury and spinal cord injury have further emerged as risks. Studies show rates of suicidality as high as 30% in the acute care setting. There are short screening instruments that can be used to universally screen for depression and suicidality in adolescent trauma patients. Step-up models of care for PTSD are promising to increase screening and services after injury. Lethal means counseling, secure firearm storage practices, and firearm safety policies can reduce the risk of suicide. Summary: Suicide is the second leading cause of death in US adolescents, and trauma patients have significant risk factors for mental illness and suicidality before and after injury. Trauma centers should strongly consider screening adolescents, establish strategies for mental health support and referrals, and provide lethal means counseling to help prevent suicide.

Pediatric Firearm Injury Mortality Epidemiology.

Firearm injury is a leading and preventable cause of death for youth in the United States. The Centers for Disease Control and Prevention web-based injury statistics query and reporting system was queried to examine changes in firearm injury mortality among youth aged 0 to 19 from 2001 to 2019. This includes assessment of overall mortality rates, mortality rates based on intent and race/ethnicity, and the proportion of deaths due to homicide, suicide, and unintentional shootings among different age groups. Regression analysis was used to identify significant differences in mortality rate over time between Black and White youth. Deaths due to firearm injury were compared with deaths due to motor vehicle traffic collisions. In 2019, firearm injuries surpassed motor vehicle collisions to become the leading cause of death for youth aged 0 to 19 years in the United States. Homicide is the most common intent across all age groups, but suicide represents a large proportion of firearm deaths in 10- to 19-year-old youth. In 2019, Black youth had a firearm mortality rate 4.3 times higher than that of White youth and a firearm homicide rate over 14 times higher than that of White youth. For each additional year after 2013, the mortality rate for Black youth increased by 0.55 deaths per 100 000 compared with White youth (time by race interaction effect P < .0001). These data indicate the growing burden of firearm injuries on child mortality and widening racial inequities with Black youth disproportionately affected by firearm violence. This public health crisis demands physician advocacy to reduce these preventable deaths among youth.

School nurse perception of asthma care in school-based telehealth.

OBJECTIVE: School-based telehealth (SBTH) offers an opportunity to overcome traditional barriers to providing comprehensive asthma care for children. Guided by an implementation science framework considering factors internal and external to the school setting, we characterized barriers and facilitators to asthma care within an existing SBTH program available in over 50 under-resourced South Carolina schools. METHODS: This cross-sectional study assessed barriers and facilitators to SBTH asthma care delivery using web-based surveys of school nurses, specifically addressing school implementation of telehealth methods. Surveys evaluated practices and nurse and school-specific factors related to telehealth implementation including perceived barriers, organizational readiness and self-efficacy. Utilizers were schools who completed 1-10 average visits per month while non-utilizers completed less than 1 average visit per month. Descriptive statistics were performed to characterize perceptions in utilizers versus non-utilizers. RESULTS: Of 53 surveys distributed, 36 were completed (68% response rate). Commonly cited barriers included inadequate time due to competing tasks in both utilizers (65%) and non-utilizers (74%) as well as lack of caregiver involvement in care planning (94% of utilizers and 84% of non-utilizers). Of those utilizing specific, relevant telehealth services, schools scored high in perceptions of organizational readiness (n = 24, mean: 24.5/30), self-efficacy (n = 26, mean: 3.6/5) and comfort with identifying students eligible for SBTH (n = 26, mean: 3.5/5). CONCLUSIONS: We identified inadequate nurse time and challenges engaging caregivers as key barriers to implementation of a school-based telehealth asthma program providing care to an under-resourced population. Addressing these barriers when expanding telehealth services may promote utilization of telehealth.

A comparison of administrative claims-based risk predictors for pediatric asthma.

OBJECTIVES: Head-to-head comparisons are needed to determine the most accurate and appropriate administrative claims-based exacerbation risk predictor for emergency department (ED) visits and hospitalizations among children with asthma. STUDY DESIGN: Retrospective cohort study. METHODS: We analyzed 2013-2014 MarketScan Medicaid data. Children aged 2 to 17 years were included. Seven risk predictors were compared for accuracy in predicting 3-month subsequent ED visits/hospitalizations for asthma: 3-month rolling asthma medication ratio (AMR), Healthcare Effectiveness Data and Information Set (HEDIS) criteria, revised HEDIS criteria, quarterly short-acting ß-agonist (SABA) claims, prior ED visit, prior hospitalization, and prior ED visit or hospitalization. Sensitivity, specificity, positive and negative predictive value (NPV), and percentage of population identified as high risk were compared for each risk predictor utilizing the McNemar test to identify statistically significant differences in risk prediction accuracy. RESULTS: A total of 214,452 children were included; the mean age was 7.8 years. HEDIS and revised HEDIS identified prohibitively large cohorts as high risk (67% and 48%, respectively). For the remaining measures, the NPV range is narrow (97%-99%), indicating high performance at identifying patients who would not benefit from intervention. The ED visit and ED/hospitalization measures have superior sensitivities (44% and 49%, respectively) compared with pharmacy claims-based measures (AMR [5%] and SABA count [10%]). Pharmacy claims-based measures identify a smaller proportion of patients as high risk and maintain high NPV. CONCLUSIONS: Pharmacy-based asthma exacerbation risk predictors such as the AMR and SABA count can rule out low-risk patients with a high degree of specificity and NPV, which is a primary goal of real-time risk monitoring in pediatric asthma.

Nurse Perspectives Regarding Implementation of an Asthma Monitoring Mobile Health Application in the School Setting.

Background: School-based telehealth (SBTH) plays a valuable role in child asthma management, although nurses have concerns with caregiver engagement. Mobile technology (m-health) has potential to improve this engagement. Objective: We identified barriers and key desired features of an asthma m-health application as a supplement to an existing SBTH asthma program in rural settings. Methods: Multimethod design using school nurse surveys and interviews with school and SBTH personnel to describe processes related to implementation of an m-health application. Results: Nurses reported SBTH programs were an ideal setting to identify potential families for m-health. Benefits of caregiver education and engagement and barriers related to technology, smart phone data availability, and family buy-in were described. Desired application features included education on inhaler technique, asthma symptom, and medication adherence reports. Conclusions: The feedback identified from nurses can be incorporated into an asthma m-health program within an SBTH program to facilitate implementation.

Increase in Mental Health Diagnoses Among Youth With Nonfatal Firearm Injuries.

BACKGROUND AND OBJECTIVES: Firearm injury is a leading cause of mortality for US youth. For every youth who dies from a firearm injury, at least 4 more survive. Little is known about the mental health consequences of non-fatal firearm injury in youth. Our objective was to quantify new mental health diagnoses after nonfatal firearm injury. METHODS: MarketScan Medicaid and commercial data were used to identify youth age 0 to 17 years with an initial encounter for a nonfatal firearm injury in 2016 to 2017. The International Classification of Diseases, Tenth Revision codes determined the presence of mental health conditions in the 12 months preinjury, during the index encounter, and in the 12 months postinjury. Logistic regression analysis was performed to determine factors associated with new mental health diagnoses during the 12 months postinjury. RESULTS: About 2178 patients (1769 Medicaid, 409 commercial) were identified for inclusion. 844 (38.8%) patients had a mental health diagnosis identified during the 12-month preinjury period. During the index encounter, 184 (8.5%) patients had a newly diagnosed mental health disorder. In the 12 months postinjury, 559 (25.7%) patients had a newly diagnosed mental health disorder. The most common new diagnosis categories were trauma disorders, substance abuse, and disruptive disorders. Medicaid insurance and a prior complex chronic condition were predictors of new mental health diagnosis. CONCLUSION: Over a quarter of youth with nonfatal firearm injury were diagnosed with a new mental health condition in the 12 months after their injury. Health care providers should be vigilant about mental health screening and ensuring access to mental health care services in this population.

Facilitators and Barriers to Implementation of School-Based Telehealth Asthma Care: Program Champion Perspectives.

OBJECTIVE: Asthma is one of the most common chronic conditions of childhood, conferring an immense burden on children and their caregivers. School-based telehealth approaches for asthma care provide the opportunity to deliver convenient, cost-effective care to more children in the school setting. Our study objective was to characterize school-based telehealth asthma program delivery experiences and examine barriers and facilitators to telehealth program implementation. METHODS: Interviews were conducted with telehealth program staff and school stakeholders in nine schools engaged in a school-based telehealth asthma program. A structured interview guide was designed using the Exploration, Adoption/Preparation, Implementation, Sustainment (EPIS) framework. A template analysis qualitative approach was used to identify themes related to implementation processes. RESULTS: Interviews identified key telehealth implementation strategies including building relationships, marketing and provision of technical assistance, education and support to aid program delivery. Key facilitators to successful program implementation included strong partnerships between the telehealth and school teams, a shared commitment to enhancing access to asthma care for children, and strong nurse leadership. Primary barriers to implementation included lack of family/caregiver involvement and competing demands for nurses. CONCLUSIONS: This study identified barriers and facilitators to implementing a school-based telehealth asthma program that can be used to guide education, training and support strategies to enhance program delivery. Recommended implementation strategies include building strong program-school partnerships, creating a shared vision to improve access to care, and building engagement in families and communities while supporting nurse leaders and family involvement with training and resources. These results can help guide future telehealth interventions.

Assessing Health Care Utilization and Compliance in Kawasaki Disease.

OBJECTIVE: To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN: We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS: The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS: Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.

Insurance Type Influences Access to Biologics and Healthcare Utilization in Pediatric Crohn's Disease.

Background: The objective of this study is to determine if there is an association between insurance status and access to biologics among children with Crohn's disease (CD). Additionally, we seek to determine differences in healthcare utilization between these groups, utilizing a national sample of children with CD. Methods: Children aged 8-18 with a diagnosis of CD were identified from 2012-2016 Truven Health MarketScan (IBM Watson Health). Patients were classified into Public/Medicaid or as Commercial/Privately Insured. Descriptive statistics were compared between groups and sensitivity analysis performed using inverse probability of treatment weighting. Adjusted differences in healthcare utilization were estimated by multiple linear regression models. Results: We identified 6163 patients with a diagnosis of CD. There were no significant differences in each payer group's demographic characteristics, comorbidities, or surgery rates. Over the 18-month follow-up period, 132 (20.4%) subjects in the public insurance group and 851 (15.4%) children in the private insurance group received biologics. Medicaid patients were 39% more likely to receive a biologic agent within 18 months of diagnosis compared to privately insured children (P = .0004). Postdiagnosis rates of hospitalizations and Emergency Department visits were significantly higher for the Medicaid group. Conclusions: In this national sample of children with CD, publicly insured children were more likely to receive a biologic within 18 months of diagnosis compared to children with private insurance. At all points in time, publicly insured children also utilized emergency room services and required hospitalization at a significantly higher rate.

Improving the Frequency and Documentation of Gun Safety Counseling in a Resident Primary Care Clinic.

OBJECTIVE: Increase the frequency and documentation of gun safety discussions during well-child checks in the pediatric primary care resident clinic to 50% within 6 months. METHODS: This is a quality improvement study in a pediatric resident continuity clinic. Before implementing any interventions, a survey was conducted to understand residents' attitudes and practices regarding gun safety screening and counseling. Interventions included a parent safety survey, Be SMART materials in clinic, and a prompt embedded into Electronic Health Record templates. Chart reviews were conducted to determine frequency of gun safety discussion. Resident self-reported comfort with gun safety counseling was also evaluated. RESULTS: A statistical process control chart was generated to track documentation and found the baseline mean rate of gun safety discussions during well-child checks was 3%. Rates increased following the addition of the Electronic Health Record prompt, with the mean further increased to 84% in July 2019. A sustained rate of over 75% was achieved through February 2020. Over 4 study months, the proportion of trainees reporting feeling very uncomfortable/uncomfortable with gun safety counseling decreased from 22% to 15%. The Be SMART program was identified as a key intervention increasing gun safety counseling. CONCLUSIONS: Our study identified an effective approach to improving the frequency and documentation of gun safety discussions in an academic primary care setting, providing a unique blueprint for firearm screening and safe storage counseling success. Ultimately, we believe this will increase safe storage behaviors in the home and reduce risks of child death from firearms.