3D Nanomagnetism in Low Density Interconnected Nanowire Networks.

Free-standing, interconnected metallic nanowire networks with densities as low as 40 mg/cm3 have been achieved over centimeter-scale areas, using electrodeposition into polycarbonate membranes that have been ion-tracked at multiple angles. Networks of interconnected magnetic nanowires further provide an exciting platform to explore 3-dimensional nanomagnetism, where their structure, topology, and frustration may be used as additional degrees of freedom to tailor the materials properties. New magnetization reversal mechanisms in cobalt networks are captured by the first-order reversal curve method, which demonstrate the evolution from strong demagnetizing dipolar interactions to intersection-mediated domain wall pinning and propagation, and eventually to shape-anisotropy dominated magnetization reversal. These findings open up new possibilities for 3-dimensional integrated magnetic devices for memory, complex computation, and neuromorphics.

Invasive Bacterial Infections in Infants Younger Than 60 Days With Skin and Soft Tissue Infections.

OBJECTIVE: The objective of this study was to describe the frequency of invasive bacterial infections (IBIs) in young infants with skin and soft tissue infections (SSTIs) and the impact of IBI evaluation on disposition, length of stay (LOS), and cost. METHODS: This retrospective (2009-2014) cohort study used data from 35 children's hospitals in the Pediatric Health Information System. We included infants younger than 60 days who presented to an emergency department (ED) with SSTI. Invasive bacterial infection was defined as bacteremia/sepsis, bone/joint infection, or bacterial meningitis. Readmission and return ED visits within 30 days were evaluated to identify missed IBIs for infants. RESULTS: A total of 2734 infants were included (median age, 33 days; interquartile range [IQR], 21-44); 62% were hospitalized. Invasive bacterial infection was identified in 2%: bacteremia (1.8%), osteomyelitis (0.1%), and bacterial meningitis (0.1%). Hospitalization occurred in 78% of infants with blood cultures, 95% with cerebrospinal fluid cultures, and 23% without cultures. Median hospitalization LOS was 2 days (IQR, 1-3). Median cost was US $4943 for infants with cerebrospinal fluid cultures (IQR, US $3475-6780) compared with US $419 (IQR, US $215-1149) for infants without IBI evaluations (P < 0.001). Five infants (0.2%) returned to the ED within 30 days with new IBI diagnoses (4 bacteremia, 1 meningitis). CONCLUSIONS: Invasive bacterial infection occurs infrequently in infants younger than 60 days who present to children's hospital EDs with SSTI. Bacteremia is the most common IBI. More extensive evaluation for IBI is associated with increased rate of admission, LOS, and cost. Further studies are needed to evaluate the safety of a limited IBI evaluation in young infants with SSTI.

Caring for Children With Medical Complexity With the Emergency Information Form.

BACKGROUND AND OBJECTIVE: The American Academy of Pediatrics recommends an emergency information form (EIF) for children with medical complexity (CMC) to facilitate emergency care. We sought to increase the EIF completion rate at our children's hospital's CMC clinic and to evaluate the effect on caregiver and emergency department (ED) provider opinion of preparation, comfort, and communication. METHODS: We used a pre/post-quality improvement design. The main outcomes were (1) the proportion of completed EIFs and (2) caregiver and ED provider opinion of preparation, comfort, and communication, using a Likert scale survey (1, low; 5, high). RESULTS: Emergency information form completion increased from 3.1% (4/133) before the intervention to 47.0% (78/166) after (P < 0.001). Twenty-three providers completed presurveys, and 8 completed postsurveys. Seventy-two caregivers completed presurveys, and 38 completed postsurveys (25 with ED visit and 13 without). There were no changes in preparation, comfort, or communication for caregivers who had an ED visit after the intervention. For those without a postintervention ED visit, caregiver median scores rose for preparation (4 [interquartile range {IQR}, 3-5] vs 5 [IQR, 4-5], P = 0.02) and comfort (4 [IQR, 2.25-5] vs 5 [IQR, 4-5], P = 0.05). After the intervention, ED providers had increased median communication scores (3 [IQR, 2.75-4.25] vs 5 [IQR, 4-5], P = 0.02), whereas scores of preparation and comfort were unchanged. CONCLUSION: A quality improvement project at a CMC clinic increased EIF completion, caregiver preparation and comfort, and ED provider communication in emergencies.

Characteristics of Infant Deaths during Sleep While Under Nonparental Supervision.

OBJECTIVE: To compare risk factors for infant sleep-related deaths under the supervision of parents and nonparents. STUDY DESIGN: We conducted a secondary analysis of sleep-related infant deaths from 2004 to 2014 in the National Center for Fatality Review and Prevention Child Death Review Case Reporting System. The main exposure was supervisor at time of death. Primary outcomes included sleep position, location, and objects in the environment. Risk factors for parental vs nonparental supervisor were compared using χ2 and multivariable logistic regression models. Risk factors associated with different nonparental supervisors were analyzed using χ2. RESULTS: Of the 10 490 deaths, 1375 (13.1%) occurred under nonparental supervision. Infants who died under nonparental supervision had higher adjusted odds of dying outside the home (OR 12.87, 95% CI 11.31-14.65), being placed prone (OR 1.61, 95% CI 1.39-1.86) or on their side (OR 1.35, 95% CI 1.12-1.62), or being found prone (OR 1.74, 95% CI 1.50-2.02). Among infants who died under nonparental supervision, those supervised by relatives or friends were more often placed on an adult bed or couch for sleep and bed sharing (P < .0001), and to have objects in the sleep environment (P = .01). CONCLUSIONS: Infants who died of sleep-related causes under nonparental supervision were more likely to have been placed nonsupine. Among nonparental supervisors, relatives and friends were more likely to use unsafe sleep environments, such as locations other than a crib or bassinet and bed sharing. Pediatricians should educate parents that all caregivers must always follow safe sleep practices.

Perspectives from the Society for Pediatric Research: interventions targeting social needs in pediatric clinical care.

The social determinants of health (SDoH) are defined by the World Health Organization as the "conditions in which people are born, grow, live, work, and age." Within pediatrics, studies have highlighted links between these underlying social, economic, and environmental conditions, and a range of health outcomes related to both acute and chronic disease. Additionally, within the adult literature, multiple studies have shown significant links between social problems experienced during childhood and "adult diseases" such as diabetes mellitus and hypertension. A variety of potential mechanisms for such links have been explored including differential access to care, exposure to carcinogens and pathogens, health-affecting behaviors, and physiologic responses to allostatic load (i.e., toxic stress). This robust literature supports the importance of the SDoH and the development and evaluation of social needs interventions. These interventions are also driven by evolving economic realities, most importantly, the shift from fee-for-service to value-based payment models. This article reviews existing evidence regarding pediatric-focused clinical interventions that address the SDoH, those that target basic needs such as food insecurity, housing insecurity, and diminished access to care. The paper summarizes common challenges encountered in the evaluation of such interventions. Finally, the paper concludes by introducing key opportunities for future inquiry.

Adding Social Determinant Data Changes Children's Hospitals' Readmissions Performance.

OBJECTIVES: To determine whether social determinants of health (SDH) risk adjustment changes hospital-level performance on the 30-day Pediatric All-Condition Readmission (PACR) measure and improves fit and accuracy of discharge-level models. STUDY DESIGN: We performed a retrospective cohort study of all hospital discharges meeting criteria for the PACR from 47 hospitals in the Pediatric Health Information database from January to December 2014. We built four nested regression models by sequentially adding risk adjustment factors as follows: chronic condition indicators (CCIs); PACR patient factors (age and sex); electronic health record-derived SDH (race, ethnicity, payer), and zip code-linked SDH (families below poverty level, vacant housing units, adults without a high school diploma, single-parent households, median household income, unemployment rate). For each model, we measured the change in hospitals' readmission decile-rank and assessed model fit and accuracy. RESULTS: For the 458 686 discharges meeting PACR inclusion criteria, in multivariable models, factors associated with higher discharge-level PACR measure included age <1 year, female sex, 1 of 17 CCIs, higher CCI count, Medicaid insurance, higher median household income, and higher percentage of single-parent households. Adjustment for SDH made small but significant improvements in fit and accuracy of discharge-level PACR models, with larger effect at the hospital level, changing decile-rank for 17 of 47 hospitals. CONCLUSIONS: We found that risk adjustment for SDH changed hospitals' readmissions rate rank order. Hospital-level changes in relative readmissions performance can have considerable financial implications; thus, for pay for performance measures calculated at the hospital level, and for research associated therewith, our findings support the inclusion of SDH variables in risk adjustment.

ICD Social Codes: An Underutilized Resource for Tracking Social Needs.

BACKGROUND: Social determinants of health (SDH) data collected in health care settings could have important applications for clinical decision-making, population health strategies, and the design of performance-based incentives and penalties. One source for cataloging SDH data is the International Statistical Classification of Diseases and Related Health Problems (ICD). OBJECTIVE: To explore how SDH are captured with ICD Ninth revision SDH V codes in a national inpatient discharge database. MATERIALS AND METHODS: Data come from the 2013 Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample, a national stratified sample of discharges from 4363 hospitals from 44 US states. We estimate the rate of ICD-9 SDH V code utilization overall and by patient demographics and payer categories. We additionally estimate the rate of SDH V code utilization for: (a) the 5 most common reasons for hospitalization; and (b) the 5 conditions with the highest rates of SDH V code utilization. RESULTS: Fewer than 2% of overall discharges in the National Inpatient Sample were assigned an SDH V code. There were statistically significant differences in the rate of overall SDH V code utilization by age categories, race/ethnicity, sex, and payer (all P<0.001). Nevertheless, SDH V codes were assigned to <7% of discharges in any demographic or payer subgroup. SDH V code utilization was highest for major diagnostic categories related to mental health and alcohol/substance use-related discharges. CONCLUSIONS: SDH V codes are infrequently utilized in inpatient settings for discharges other than those related to mental health and alcohol/substance use. Utilization incentives will likely need to be developed to realize the potential benefits of cataloging SDH information.

Evaluating the Accountable Health Communities Demonstration Project.

Despite substantial evidence documenting the social patterning of disease, relatively little information is available on how the health care system can best intervene on social determinants to impact individual and population health. Announced in January 2016, the Centers for Medicare and Medicaid Innovation's (CMMI) Accountable Health Communities (AHC) initiative provides an important opportunity to improve the evidence base around integrated social and medical care delivery. To maximize learning from this large-scale demonstration, comprehensive evaluation efforts should focus on effectiveness and implementation research by supporting local, regional, and national studies across a range of outcomes. Findings from this demonstration could transform how, when, and which patients' health-related social needs are addressed within the health care delivery system. Such findings would strongly complement other initiatives to address social factors outside of health care.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury.

OBJECTIVE: To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI). STUDY DESIGN: Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income. RESULTS: There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs. CONCLUSIONS: Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Income and Household Material Hardship in Children With Medical Complexity.

BACKGROUND AND OBJECTIVES: Household economic hardship negatively impacts child health but may not be adequately captured by income. We sought to determine the prevalence of household material hardship (HMH), a measure of household economic hardship, and to examine the relationship between household poverty and material hardship in a population of children with medical complexity. METHODS: We conducted a cross-sectional survey study of parents of children with medical complexity receiving primary care at a tertiary children's hospital. Our main predictor was household income as a percentage of the federal poverty limit (FPL): <50% FPL, 51% to 100% FPL, and >100% FPL. Our outcome was HMH measured as food, housing, and energy insecurity. We performed logistic regression models to calculate adjusted odds ratios of having ≥1 HMH, adjusted for patient and clinical characteristics from surveys and the Pediatric Health Information System. RESULTS: At least 1 material hardship was present in 40.9% of participants and 28.2% of the highest FPL group. Families with incomes <50% FPL and 51% to 100% FPL had ∼75% higher odds of having ≥1 material hardship compared with those with >100% FPL (<50% FPL: odds ratio 1.74 [95% confidence interval: 1.11-2.73], P = .02; 51% to 100% FPL: 1.73 [95% confidence interval: 1.09-2.73], P = .02). CONCLUSIONS: Poverty underestimated household economic hardship. Although households with incomes <100% FPL had higher odds of having ≥1 material hardship, one-quarter of families in the highest FPL group also had ≥1 material hardship.

Changes in hospitalization populations by level of complexity at children's hospitals.

It is important for hospitals to understand how hospitalizations for children are changing to adapt and best accommodate the future needs of all patient populations. This study aims to understand how hospitalizations for children with medical complexity (CMC) and non-CMC have changed over time at children's hospitals, and how hospitalizations for these children will look in the future. Children with 3+ complex chronic conditions (CCC) accounted for 7% of discharges and over one-quarter of days and one-third of costs during the study period (2012-2022). The number of CCCs was associated with increased growth in discharges, hospital days, and costs. Understanding these trends can help hospitals better allocate resources and training to prepare for pediatric patients across the spectrum of complexity.

Effectiveness of Screening for Household Gun Ownership in an Urban Primary Care Clinic.

Gun-related suicide and homicide are leading causes of death among children. Little is known about the effectiveness of screening for gun ownership in primary care. We examined positive gun ownership screens over a 2.5-year period in a pediatric primary care clinic. The main outcome was a positive screen for gun ownership. The main predictors included insurance type, neighborhood median income, number of clinic visits, and other social needs. Of 19 163 patients, 474 (2.5%) screened positive for gun ownership. Patients with private insurance and from higher income neighborhoods had 2 to 3 times higher odds of a positive screen. Patients with more visits and with food insecurity had approximately 2 to 4 times the odds of a positive screen for household gun ownership. In conclusion, the rate of positive gun ownership screens was very low and far below known gun ownership rates. Improved screening methods could better identify opportunities for gun safety advocacy.

Accuracy of the Exeter Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns Index for Identifying Children With Complex Chronic Medical Conditions in the Clinical Setting.

OBJECTIVE: Our objective was to determine the accuracy of a point-of-care instrument, the Hospitalizations-Office Visits-Medical Conditions-Extra Care-Social Concerns (HOMES) instrument, in identifying patients with complex chronic conditions (CCCs) compared to an algorithm used to identify patients with CCCs within large administrative data sets. METHODS: We compared the HOMES to Feudtner's CCCs classification system. Using administrative algorithms, we categorized primary care patients at a children's hospital into 3 categories: no chronic conditions, non-complex chronic conditions, and CCCs. We randomly selected 100 patients from each category. HOMES scoring was completed for each patient. We performed an optimal cut-point analysis on 80% of the sample to determine which total HOMES score best identified children with ≥1 CCC and ≥2 CCCs. Using the optimal cut points and the remaining 20% of the study population, we determined the odds and area under the curve (AUC) of having ≥1 CCC and ≥2 CCCs. RESULTS: The median (interquartile range [IQR]) age was 4 (IQR: 0, 8). Using optimal cut points of ≥7 for ≥1 CCC and ≥11 for ≥2 CCCs, the odds of having ≥1 CCC was 19 times higher than lower scores (odds ratio [OR] 19.1 [95% confidence interval [CI]: 9.75, 37.5]) and of having ≥2 CCCs was 32 times higher (OR 32.3 [95% CI: 12.9, 50.6]). The AUCs were 0.76 for ≥1 CCC (sensitivity 0.82, specificity 0.80) and 0.74 for ≥2 CCCs (sensitivity 0.92, specificity 0.74). CONCLUSIONS: The HOMES accurately identified patients with CCCs.

Health and Poverty of Rural Children: An Under-Researched and Under-Resourced Vulnerable Population.

Nearly 1 in 5 children in the United States live in rural areas. Rural children experience health and health care disparities compared to their urban peers and represent a unique and vulnerable pediatric patient population. Important disparities exist in all-cause mortality, suicide, firearm-related unintentional injury, and obesity. Rural children experience decreased availability and accessibility of primary care and specialty care (especially mental health care) due to a decreased number of health care providers as well as geographical and transportation-related barriers. Other geographic and socioeconomic determinants, especially concerning poverty and substandard housing conditions, are likely important contributors to the observed health disparities. Increased funding for research focused on rural populations is needed to provide innovative solutions for the unique health needs of rural children. Policy changes positioned to correct the trajectory of poor health among children should consider the needs of rural children as an under-researched and under-resourced vulnerable population.

Agreement of Provider and Parent Perceptions of Complex Care Medical Homes After a Care Management Intervention.

INTRODUCTION: Children with medical complexity frequently lack coordinated and family-centered care and are best cared for in a medical home. METHOD: We assessed concordance between provider and family perceptions of care management improvements during a prospective, 3-year study of nine complex care clinics and 42 primary care clinics. Using a pre-post design, we compared provider and parent perceptions of changes in care coordination and family-centered care responses using paired t tests, Spearman rank correlations, and linear regression. RESULTS: Provider scores significantly increased in every domain (range: 14.1 points [data management], 23.0 points [chronic care management]; p < .001). Parent perceptions improved only for shared decision making improved significantly (2.2 points, p < .01). DISCUSSION: These results indicate that it is possible to improve the medical home for children with medical complexity through a quality improvement initiative, but that provider perception of the improvement may be greater than parents' perceptions.

Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions.

BACKGROUND: Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. METHODS: This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. RESULTS: There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CONCLUSIONS: CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.

Economy-Sensitive Conditions: Are Some Pediatric Hospitalizations Triggered By Economic Recessions?

The impact of economic recessions on child health is complex and varied. Here we examine associations between county-level unemployment and pediatric hospitalizations in fourteen states every third year from 2002 to 2014. After adjusting for state-specific effects of unemployment across all counties and years, we found that increased unemployment was associated with increased pediatric hospitalizations for four potentially economy-sensitive conditions, such that a 1 percent increase in unemployment was associated with a 5 percent increase in hospitalizations for substance abuse, a 4 percent increase for diabetes mellitus, and a 2 percent increase both for children with medical complexity and for poisoning and burns. Mean pediatric all-cause hospitalizations increased by 2 percent for every 1 percent increase in unemployment (or 54,177 excess hospitalizations in 2011 compared with 2005). Hospitalizations for mental health, despite the increased severity of these conditions during recessions, were not associated with unemployment. Further research is needed to examine potential federal, state, and local policies that may mitigate the influence of unemployment on child health and pediatric hospitalizations.

Parental Perceptions of Culturally Sensitive Care and Well-Child Visit Quality.

OBJECTIVE: Incorporating culturally sensitive care into well-child visits may help address pediatric preventive care disparities faced by racial and ethnic minorities, families with limited English proficiency, and immigrants. We explored parents' perspectives about the extent to which their children's pediatric care is culturally sensitive and potential associations between culturally sensitive care and well-child visit quality. METHODS: We conducted cross-sectional surveys with parents attending a well-child visit for a child ages 3 to 48 months. To measure culturally sensitive care, we created a composite score by averaging 8 subscales from an adapted version of the Clinicians' Cultural Sensitivity Survey. We assessed well-child visit quality through the Promoting Healthy Development Survey. Multivariate linear regression was used to understand associations between demographic characteristics and parent-reported culturally sensitive care. We used multivariate logistic regression to examine associations between culturally sensitive care and well-child visit quality. RESULTS: Two hundred twelve parents (71% of those approached) completed the survey. Parents born abroad, compared with those born in the United States, reported significantly higher culturally sensitive care scores (+0.21; confidence interval [CI]: 0.004, 0.43). Haitian parents reported significantly lower culturally sensitive care scores compared with non-Hispanic white parents (-0.49; CI: -0.89, -0.09). Parent-reported culturally sensitive care was significantly associated with higher odds of well-child visit quality including receipt of anticipatory guidance (adjusted odds ratio: 2.68; CI: 1.62, 4.62) and overall well-child visit quality (adjusted odds ratio: 2.54; CI: 1.59, 4.22). CONCLUSIONS: Consistent with prior research of adult patients, this study demonstrates an association between parent-reported culturally sensitive care and well-child visit quality. Future research should explore best practices to integrating culturally sensitive care in pediatric preventive health care settings.

Care of Pediatric High-Cost Hospitalizations Across Hospital Types.

BACKGROUND: High-cost hospitalizations (HCHs) account for a substantial proportion of pediatric health care expenditures. We aimed to (1) describe the distribution of pediatric HCHs across hospital types caring for children and (2) compare characteristics of pediatric HCHs by hospital type. METHODS: Cross-sectional analysis of all pediatric hospitalizations in the 2012 Kids' Inpatient Database. HCHs were defined as costs >$40 000 (94th percentile). Hospitals were categorized as children's, small general, and large general. RESULTS: Approximately 166 000 HCHs were responsible for 50.8% of aggregate hospital costs ($18.1 of $35.7 billion) and were mostly at children's hospitals (65%). Children with an HCH were largely neonates (45%), had public insurance (50%), and had ≥1 chronic condition (74%). A total of 131 children's hospitals cared for a median of 559 HCHs per hospital (interquartile range [IQR]: 355-1153) compared to 76 HCHs per hospital (IQR: 32-151) at 397 large general hospitals and 5 HCHs per hospital (IQR: 2-22) at 3581 small general hospitals. The median annual aggregate cost for HCHs was $60 million (IQR: $36-$135) per children's hospital compared to $6.6 million (IQR: $2-$15) per large general hospital and $300 000 (IQR: $116 000-$1.5 million) per small general hospital. HCHs from children's hospitals encompassed nearly 5 times as many unique clinical conditions as large general hospitals and >30 times as many as small general hospitals. CONCLUSIONS: Children's hospitals cared for a disproportionate volume, cost, and diversity of HCHs compared to general hospitals. Future studies should characterize the factors driving cost, resources, and reimbursement practices for HCH to ensure the long-term financial viability of the pediatric health care system.