Vidya Sharma

How Well Can Hospital Readmission Be Predicted in a Cohort of Hospitalized Children? A Retrospective, Multicenter Study

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS. This was a retrospective cohort study. Hospital administrative data were collected from 38 childrens hospitals in the United States for the years 2003–2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Atopic Dermatitis in Children in the United States, 1997–2004: Visit Trends, Patient and Provider Characteristics, and Prescribing Patterns

OBJECTIVE. Atopic dermatitis is the most common chronic inflammatory skin disease of childhood and is increasing in prevalence throughout the world. Morbidity and resource use for atopic dermatitis are comparable to other chronic diseases. Topical corticosteroids are first-line therapeutic agents for atopic dermatitis; topical calcineurin inhibitors are considered second-line agents for patients who are older than 2 years. The aims of this study were to examine trends in visits for atopic dermatitis in children in the United States between 1997 and 2004, identify factors that were associated with a pediatric visit for atopic dermatitis, and assess changes in the treatment of atopic dermatitis over time. METHODS. Visits for atopic dermatitis by children (0–18 years) to office-based physicians and hospital outpatient departments using 1997–2004 National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey databases were analyzed. Medication prescribing rates during 2 time periods (1997–2000 and 2001–2004) were also analyzed. RESULTS. There were an estimated 7.4 million visits for atopic dermatitis. Statistically significant differences in patients with atopic dermatitis included age 2 to 5 years, black race, Asian race, and specialist or hospital outpatient clinic evaluation. The increase in atopic dermatitis visits per year was statistically significant. No statistical differences in prescribing rates were identified between the 2 time periods. Between 1997 and 2000, topical corticosteroids were prescribed in 34% of visits, decreasing to 25% between 2001 and 2004. Between 2001 and 2004, topical calcineurin inhibitors were prescribed in 23% of visits. In the same period, topical corticosteroids were prescribed in 24% of visits by children who were younger than 2 years; topical calcineurin inhibitors were prescribed in 22% of visits. CONCLUSIONS. Visits for atopic dermatitis in children are increasing. A recommended first-line treatment was prescribed in a minority of the visits.

Impact of rapid influenza testing at triage on management of febrile infants and young children

Objective: To determine the impact of an emergency department (ED) triage protocol for rapid influenza testing of febrile infants and children on additional diagnostic testing, ED charges and patient time in the ED. Methods: A trial of triage-based rapid influenza A and B testing of febrile infants and children 3 to 36 months of age presenting to an urban ED during December 2002 to March 2003 was performed. Children with a temperature of 39°C or higher or history of fever 102°F or higher at home were included. Those with obvious focal infection, potential immunodeficiency, and indwelling medical devices were excluded. The intervention group, tested for influenza at triage (TT) was compared with a nonintervention group consisting of those receiving usual care (SP). A subanalysis comparing influenza-positive children was performed. Results: Of 1007 eligible subjects a total of 719 (71%) patients were in the SP group and 288 in the TT group. There were significant differences in respiratory syncytial virus rapid test (RSV; 18%-7%) and chest radiographs (CXRs; 26%-20%) tests in the TT group. In addition, significant increases in obtaining a complete blood count (relative risk [RR] 12.0; 95% confidence interval [CI] 2.9-49), blood culture (RR, 12.0; 95% CI, 3.0-51.0), RSV testing (RR, 0.9.2; 95% CI, 3.4-25.0), urinalysis (RR, 5.7; 95% CI, 2.0-16.0), CXR (RR, 2.2; 95% CI, 1.04-4.5), time in the ED (195 vs 156 minutes; 95% CI, of the difference 19-60), and medical charges (

Factors Influencing Infant Visits to Emergency Departments

666 vs

A Multicenter Study of Factors Influencing Cerebrospinal Fluid Shunt Survival in Infants and Children

393; 95% CI, of the difference 153-392) were seen among those testing positive for influenza in the SP group. Conclusions: A triage protocol for rapid influenza testing for febrile infants and children appears to significantly decrease additional testing, time in the ED, and charges in children testing positive for influenza.

A multi-institutional, 5-year analysis of initial and multiple ventricular shunt revisions in children.

Objectives. To follow the 1995 birth cohort of infants, born in the State of Missouri, through their first birthday to: 1) examine their rates of visits to emergency departments (EDs), 2) identify predictors of any ED visit, 3) examine rates of nonurgent ED visits, and 4) identify predictors of nonurgent visits. Methods. This was a retrospective population cohort study. Using deterministic linkage procedures, 2 databases at the Missouri Department of Health (DOH; (the patient abstract database and the birth registry database) were linked by DOH personnel. International Classification of Diseases, Ninth Revision-Clinical Modification codes for ED visits were classified as emergent, urgent, or nonurgent by 2 researchers. Eight newborn characteristics were chosen for analysis. Negative binomial regression was used to examine the rates and predictors of both total and nonurgent ED visits. Results. There were 935 total ED visits and 153 nonurgent ED visits per 1000 infant years. The average number of visits was .94, with 59% of infants having no visits, 21% having 1 ED visit, and 20% having 2 or more visits. Factors associated with increases in both total and nonurgent ED visits were Medicaid, self-pay, black race, rural region, presence of birth defects, and a nursery stay of >2 days. Significant interactions were found between Medicaid and race and Medicaid and rural regions on rates of ED use and nonurgent use. The highest rate of ED use, 1.8 per person year, was seen in white, rural infants on Medicaid, and the lowest rate (.4 per person year) was seen in urban white infants not on Medicaid. The highest rates of nonurgent use, .3 per person year, were among urban and rural Medicaid infants of both races and among black infants on commercial insurance. The lowest nonurgent rate, .04 per person year, was seen in white urban infants on commercial insurance. Conclusion. Infants in the State of Missouri have high rates of ED visits. Nonurgent visits are only a small portion of ED visits and cannot explain large variations in ED usage. Increased ED use by Medicaid patients may reflect continuing difficulties in accessing primary care.

Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

OBJECTIVES To identify factors influencing the duration of cerebrospinal fluid shunt survival after initial placement and after subsequent revisions. METHODS We conducted a retrospective cohort study using the Pediatric Health Information System database, which contains resource use data from 37 tertiary care childrens hospitals. Children younger than 18 years who underwent initial cerebrospinal fluid placement between January 1, 2000, and December 31, 2005, were eligible. RESULTS During the study period, 20.2, 7.5, and 6.9% of 7399 patients required one, two, or three or more shunt revisions, respectively. Shunt survival rates were lower with each subsequent shunt revision. In multivariable Cox proportional hazards analysis, children undergoing shunt placement in the Northeast census region had a longer duration of shunt survival between initial placement and both the first (adjusted hazard ratio, 0.74; 95% confidence interval, 0.55-0.99) and second (adjusted hazard ratio, 0.66; 95% confidence interval, 0.51-0.86) revisions. Young age and a principal diagnosis of obstructive hydrocephalus were also associated with a higher risk of failure after initial placement; age-related variation in shunt survival persisted after the first but not the second revision. Among patients with multiple shunt revisions, those with early revision (i.e., revision <60 d after placement) had a shorter shunt survival time after subsequent revisions (adjusted hazard ratio for second revision, 1.30; 95% confidence interval, 1.11-1.52). CONCLUSIONS Regional variation in the risk of ventricular shunt revision exists, and young infants are at the highest risk for shunt failure. Risk factors for the duration of shunt survival differ between the initial and subsequent revisions.

Timing of Follow-up Voiding Cystourethrogram in Children With Primary Vesicoureteral Reflux: Development and Application of a Clinical Algorithm

OBJECTIVE To evaluate risk factors and predictors of cerebrospinal ventricular shunt revisions in children. METHODS A retrospective, longitudinal cohort of 1307 children ages 0 to 18 years undergoing initial ventricular shunt placement in the year 2000, with follow-up through 2005, from 32 freestanding childrens hospitals within the Pediatric Health Information Systems database was studied. Rates of ventricular shunt revision were compared with patient demographic, clinical, and hospital characteristics with use of bivariate and multivariate regression accounting for hospital clustering. RESULTS Thirty-seven percent of children required at least one shunt revision within 5 years of initial shunt placement; 20% of children required two or more revisions. Institutional rates of first shunt revision ranged from 20 to 70% of initial shunts placed among the 32 hospitals in the cohort. Hospitals where one to 20 initial shunt placements per year experienced the highest initial shunt revision rate (42%). Hospitals performing over 83 initial shunt placements per year experienced the lowest revision rate (22%). We found that children undergoing shunt placement in the Midwest were more likely to experience multiple shunt revisions (odds ratio, 1.25; 95% confidence interval, 1.06-1.47) after controlling for hospital volume, shunt type, age, and diagnosis associated with initial shunt placement. CONCLUSION Higher hospital volume of initial shunt placement was associated with lower revision rates. Substantial hospital variation in the rates of ventricular shunt revision exists among childrens hospitals. Future prospective studies are needed to examine the reasons for the variability in shunt revision rates among hospitals, including differences in specific processes of care.

Benchmarks for the Emergency Department Care of Children With Asthma, Bronchiolitis, and Croup

OBJECTIVE. The goal was to measure US emergency department performance in the pediatric care of asthma, bronchiolitis, and croup, by using systematically developed quality indicators. METHODS. Data on visits to emergency departments by children 1 to 19 years of age with moderate/severe asthma, 3 months to 2 years of age with bronchiolitis, and 3 months to 3 years of age with croup from the 2005 National Hospital Ambulatory Medical Care Survey, with a nationally representative sample of US patients, were analyzed. We used national rates of use of corticosteroids, antibiotics, and radiographs as our main outcome measures. RESULTS. Physicians prescribed corticosteroids in 69% of the estimated 405 000 annual visits for moderate/severe asthma and in 31% of the estimated 317 000 annual croup visits. Children with bronchiolitis received antibiotics in 53% of the estimated 228 000 annual visits. Physicians obtained radiographs in 72% of bronchiolitis visits and 32% of croup visits. CONCLUSIONS. Physicians treating children with asthma, bronchiolitis, and croup in US emergency departments are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

Background and Objectives. Of children diagnosed with urinary tract infection, 30% to 40% have primary vesicoureteral reflux (VUR). For the majority of these children, treatment involves long-term prophylactic antibiotics (ABX) and a periodic voiding cystourethrogram (VCUG) until resolution of VUR as detected by VCUG. Radiation exposure and considerable discomfort have been associated with VCUG. To date, no clear guidelines exist regarding the timing of follow-up VCUGs. The objective of this study was to develop a clinically applicable algorithm for the optimal timing of repeat VCUGs and validate this algorithm in a retrospective cohort of children with VUR. Methods. Based on previously published data regarding the probability of resolution of VUR over time, a decision-tree model (DTM) was developed. The DTM compared the differential impact of 3 timing schedules of VCUGs (yearly, every 2 years, and every 3 years) on the average numbers of VCUGs performed, years of ABX exposure, and overall costs. Based on the DTM, an algorithm optimizing the timing of VCUG was developed. The algorithm then was validated in a retrospective cohort of patients at an urban pediatric referral center. Data were extracted from the medical records regarding number of VCUGs, time of ABX prophylaxis, and complications associated with either. VUR in patients in the cohort was grouped into mild VUR (grades I and II and unilateral grade III for those ≤2 years old), and moderate/severe VUR (other grade III and grade IV). Kaplan-Meier survival curves were created from the cohort data. From the survival curves, the median times to resolution of VUR were determined for the cohort, and these times were compared with the median times to VUR resolution of the data used for the DTM. The numbers of VCUGs performed, time of ABX exposure, and costs in the cohort were compared with those that would have occurred if the algorithm had been applied to both mild and moderate/severe VUR groups. Results. Using an algorithm that results in a recommendation of VCUGs every 2 years in mild VUR would reduce the average number of VCUGs by 42% and costs by 33%, with an increase in ABX exposure of 16%, compared with a schedule of yearly VCUGs. For moderate/severe VUR, a VCUG performed every 3 years would reduce the average number of VCUGs by 63% and costs by 51%, with an increase in ABX exposure of 10%. Applying this algorithm to the retrospective cohort consisting of 76 patients (between 1 month and 10 years old) with primary VUR would have reduced overall VCUGs by 19% and costs by 6%, with an increase in ABX exposure of 26%. The patterns of VUR resolution, age distribution, and prevalence of severity of VUR were comparable between previously published results and the retrospective cohort. Conclusions. Delaying the schedule of VCUG from yearly to every 2 years in children with mild VUR and every 3 years in children with moderate/severe VUR yields substantial reductions in the average numbers of VCUGs and costs, with a modest subsequent increase in ABX exposure.