Isabella Zaniletti

Socioeconomic Status and In-Hospital Pediatric Mortality

OBJECTIVE: Socioeconomic status (SES) is inversely related to pediatric mortality in the community. However, it is unknown if this association exists for in-hospital pediatric mortality. Our objective was to determine the association of SES with in-hospital pediatric mortality among children’s hospitals and to compare observed mortality with expected mortality generated from national all-hospital inpatient data. METHODS: This is a retrospective cohort study from 2009 to 2010 of all 1 053 101 hospitalizations at 42 tertiary care, freestanding children’s hospitals. The main exposure was SES, determined by the median annual household income for the patient’s ZIP code. The main outcome measure was death during the admission. Primary outcomes of interest were stratified by income and diagnosis-based service lines. Observed-to-expected mortality ratios were created, and trends across quartiles of SES were examined. RESULTS: Death occurred in 8950 (0.84%) of the hospitalizations. Overall, mortality rates were associated with SES (P < .0001) and followed an inverse linear association (P < .0001). Similarly, observed-to-expected mortality was associated with SES in an inverse association (P = .014). However, mortality overall was less than expected for all income quartiles (P < .05). The association of SES and mortality varied by service line; only 3 service lines (cardiac, gastrointestinal, and neonatal) demonstrated an inverse association between SES and observed-to-expected mortality. CONCLUSIONS: Within children’s hospitals, SES is inversely associated with in-hospital mortality, but is lower than expected for even the lowest SES quartile. The association between SES and mortality varies by service line. Multifaceted interventions initiated in the inpatient setting could potentially ameliorate SES disparities in in-hospital pediatric mortality.

The Children’s Hospitals Neonatal Database: an overview of patient complexity, outcomes and variation in care

The Childrens Hospitals Neonatal Consortium is a multicenter collaboration of leaders from 27 regional neonatal intensive care units (NICUs) who partnered with the Childrens Hospital Association to develop the Childrens Hospitals Neonatal Database (CHND), launched in 2010. The purpose of this report is to provide a first summary of the population of infants cared for in these NICUs, including representative diagnoses and short-term outcomes, as well as to characterize the participating NICUs and institutions. During the first 2 1/2 years of data collection, 40910 infants were eligible. Few were born inside these hospitals (2.8%) and the median gestational age at birth was 36 weeks. Surgical intervention (32%) was common; however, mortality (5.6%) was infrequent. Initial queries into diagnosis-specific inter-center variation in care practices and short-term outcomes, including length of stay, showed striking differences. The CHND provides a contemporary, national benchmark of short-term outcomes for infants with uncommon neonatal illnesses. These data will be valuable in counseling families and for conducting observational studies, clinical trials and collaborative quality improvement initiatives.

Short-term outcomes after perinatal hypoxic ischemic encephalopathy: a report from the Children’s Hospitals Neonatal Consortium HIE focus group

Objective:To characterize infants affected with perinatal hypoxic ischemic encephalopathy (HIE) who were referred to regional neonatal intensive care units (NICUs) and their related short-term outcomes.Study Design:This is a descriptive study evaluating the data collected prospectively in the Children’s Hospital Neonatal Database, comprised of 27 regional NICUs within their associated children’s hospitals. A consecutive sample of 945 referred infants born ⩾36 weeks’ gestation with perinatal HIE in the first 3 days of life over approximately 3 years (2010–July 2013) were included. Maternal and infant characteristics are described. Short-term outcomes were evaluated including medical comorbidities, mortality and status of survivors at discharge.Result:High relative frequencies of maternal predisposing conditions, cesarean and operative vaginal deliveries were observed. Low Apgar scores, profound metabolic acidosis, extensive resuscitation in the delivery room, clinical and electroencephalographic (EEG) seizures, abnormal EEG background and brain imaging directly correlated with the severity of HIE. Therapeutic hypothermia was provided to 85% of infants, 15% of whom were classified as having mild HIE. Electrographic seizures were observed in 26% of the infants. Rates of complications and morbidities were similar to those reported in prior clinical trials and overall mortality was 15%.Conclusion:Within this large contemporary cohort of newborns with perinatal HIE, the application of therapeutic hypothermia and associated neurodiagnostic studies appear to have expanded relative to reported clinical trials. Although seizure incidence and mortality were lower compared with those reported in the trials, it is unclear whether this represented improved outcomes or therapeutic drift with the treatment of milder disease.

Community Household Income and Resource Utilization for Common Inpatient Pediatric Conditions

BACKGROUND AND OBJECTIVE: Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI). METHODS: Retrospective national cohort from 32 freestanding children’s hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups. RESULTS: From 116 636 hospitalizations, 4 of 5 conditions had differences at the hospitalization and at the patient level, with lowest-income groups having higher costs. The individual hospitalization level cost differences ranged from

SLUG Bug: Quality Improvement With Orchestrated Testing Leads to NICU CLABSI Reduction.

187 (4.1%) to

Therapeutic interventions and short-term outcomes for infants with severe bronchopulmonary dysplasia born at <32 weeks' gestation.

404 (6.4%). Patient-level cost differences ranged from

Predicting death or extended length of stay in infants with congenital diaphragmatic hernia

310 to

High surgical burden for infants with severe chronic lung disease (sCLD)

1087 or 6.5% to 15% higher for the lowest-income patients. Higher costs were typically not for laboratory, imaging, or pharmacy costs. In total, patients from lowest income zip codes had

Intercenter Cost Variation for Perinatal Hypoxic-Ischemic Encephalopathy in the Era of Therapeutic Hypothermia.

8.4 million more in hospitalization-level costs and

Orchestrated Testing An Innovative Approach to a Multicenter Improvement Collaborative

13.6 million more in patient-level costs. CONCLUSIONS: Lower community-level HHI is associated with higher inpatient costs of care for 4 of 5 common pediatric conditions. These findings highlight the need to consider socioeconomic status in health care system design, delivery, and reimbursement calculations.