Search

Background and Objectives: Children with medical complexity (CMC) are high health care utilizers prompting hospitals to implement care models focused on this population, yet practices have not been evaluated on a national level. Our objective with this study is to describe the presence and structure of care models and the use of discharge services for CMC admitted to freestanding children's hospitals across the nation., Methods: We distributed an electronic survey to 48 hospitals within the Pediatric Health Information System exploring the availability of care models and discharge services for CMC. Care models were grouped by type and number present at each institution. Discharge services were grouped by low (never, rarely), medium (sometimes), and high (most of the time, always) frequency use., Results: Of 48 eligible hospitals, 33 completed the survey (69%). There were no significant differences between responders and non-responders for both hospital and patient characteristics. Most participants identified an outpatient care model (67%), whereas 21% had no dedicated care model for CMC in the inpatient or outpatient setting. High-frequency discharge services included durable medical equipment delivery, medication delivery, and communication with outpatient provider before discharge. Low-frequency discharge services included the use of a structured handoff tool for outpatient communication, personalized access plans, inpatient team follow-up with family after discharge, and the use of discharge checklists., Conclusions: Children's hospitals vary largely in care model structure and discharge services. Future work is needed to evaluate the associations between care models and discharge services for CMC with various health care outcomes., (Copyright © 2024 by the American Academy of Pediatrics.)

Background and Objectives: Moderate and late preterm infants are a growing subgroup of neonates with increased care needs after birth, yet standard protocols are lacking. We aim to describe variation in length of stay (LOS) by gestational age (GA) across hospitals within the same level of neonatal care and between different levels of neonatal care., Methods: Retrospective cohort study of hospitalizations for moderate (32-33 weeks GA) and late (34-36 weeks GA) preterm infants in 2019 Kid's Inpatient Database. We compared adjusted LOS in this cohort and evaluated variation within hospitals of the same level and across different levels of neonatal care., Results: This study includes 217 051 moderate (26.2%) and late (73.8%) preterm infants from level II (19.7%), III (66.3%), and IV (11.1%) hospitals. Patient-level (race and ethnicity, primary payor, delivery type, multiple gestation, birth weight) and hospital-level (birth region, level of neonatal care) factors were significantly associated with LOS. Adjusted mean LOS varied for hospitals within the same level of neonatal care with level II hospitals showing the greatest variability among 34- to 36- week GA infants when compared with level III and IV hospitals (P < .01). LOS also varied significantly between levels of neonatal care with the greatest variation (0.9 days) seen in 32-week GA between level III and level IV hospitals., Conclusions: For moderate and late preterm infants, the level of neonatal care was associated with variation in LOS after adjusting for clinical severity. Hospitals providing level II neonatal care showed the greatest variation and may provide an opportunity to standardize care., (Copyright © 2024 by the American Academy of Pediatrics.)

Objective: Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations., Methods: Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions., Results: The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75])., Conclusions: Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations., (Copyright © 2023 by the American Academy of Pediatrics.)

Context: Spatial analysis is a population health methodology that can determine geographic distributions of asthma outcomes and examine their relationship to place-based social determinants of health (SDOH)., Objectives: To systematically review US-based studies analyzing associations between SDOH and asthma health care utilization by geographic entities., Data Sources: Pubmed, Medline, Web of Science, Scopus, and Cumulative Index to Nursing and Allied Health Literature., Study Selection: Empirical, observational US-based studies were included if (1) outcomes included asthma-related emergency department visits or revisits, and hospitalizations or rehospitalizations; (2) exposures were ≥1 SDOH described by the Healthy People (HP) SDOH framework; (3) analysis occurred at the population-level using a geographic entity (eg, census-tract); (4) results were reported separately for children ≤18 years., Data Extraction: Two reviewers collected data on study information, demographics, geographic entities, SDOH exposures, and asthma outcomes. We used the HP SDOH framework's 5 domains to organize and synthesize study findings., Results: The initial search identified 815 studies; 40 met inclusion criteria. Zip-code tabulation areas (n = 16) and census-tracts (n = 9) were frequently used geographic entities. Ten SDOH were evaluated across all HP domains. Most studies (n = 37) found significant associations between ≥1 SDOH and asthma health care utilization. Poverty and environmental conditions were the most often studied SDOH. Eight SDOH-poverty, higher education enrollment, health care access, primary care access, discrimination, environmental conditions, housing quality, and crime - had consistent significant associations with asthma health care utilization., Conclusions: Population-level SDOH are associated with asthma health care utilization when evaluated by geographic entities. Future work using similar methodology may improve this research's quality and utility., (Copyright © 2023 by the American Academy of Pediatrics.)

Objectives: The objectives of this study are to (1) describe our postdischarge telemedicine program and (2) evaluate program implementation., Methods: At our single-center tertiary care children's hospital, we launched our postdischarge telemedicine program in April 2020. We used the Template for Intervention Description and Replication framework to describe our pilot program and Proctor's conceptual framework to evaluate implementation over a 9-month period. Retrospective chart review was conducted. Descriptive analyses were used to compare demographics and health care reutilization rates across patients. Implementation outcomes included adoption (rate of scheduled visits) and feasibility (rate of completed visits). Effectiveness outcomes included the rate of postdischarge issues and unscheduled healthcare utilization., Results: We established a postdischarge telemedicine program for a general pediatric population that ensured follow-up at a time when in-person evaluation was limited because of the coronavirus disease 2019 pandemic. For implementation evaluation, we included all 107 patients in the pilot program. Adoption was 100% and feasibility was 58%. Eighty-two percent of patients completing a visit reported one or more postdischarge issues. There was no difference in health system reutilization between those who completed a visit and those who did not., Conclusions: Implementation of a postdischarge telemedicine service is achievable and promotes early detection of failures in the hospital to home transition. Directions for future study will include rigorous program evaluation via telemedicine program assessment tools and sustainability efforts that build upon known implementation and health service outcomes., (Copyright © 2023 by the American Academy of Pediatrics.)

Background and Objective: During the coronavirus disease 2019 pandemic, technology-dependent children are at risk of encountering barriers to hospital discharge because of limits to in-home services. Transition difficulties could increase length of stay (LOS). With this study, we aim to (1) evaluate change in LOS and (2) describe barriers to hospital discharge between prepandemic and early pandemic periods for technology-dependent children., Methods: A retrospective chart review of technology-dependent children discharged from an acute and specialty pediatric hospital within a single urban area between January 1 and May 28, 2020 was conducted. Technology dependence was defined by using a validated complex chronic condition coding system. Patients discharged prepandemic and during the pandemic were compared. Outcomes included LOS and the number and type of discharge barriers (a factor not related to a medical condition that delays discharge). Multivariate regression modeling and parametric and nonparametric analysis were used to compare cohorts., Results: Prepandemic, 163 patients were discharged, and 119 were discharged during the early stages of the pandemic. The most common technology dependence was a feeding tube. The unadjusted median LOS was 7 days in both groups. After adjusting for patient-level factors, discharge during the pandemic resulted in a 32.2% longer LOS (confidence interval 2.1%-71.2%). The number of discharge barriers was high but unchanged between cohorts. Lack of a trained caregiver was more frequent during the pandemic (P = .03)., Conclusions: Barriers to discharge were frequent for both cohorts. Discharge during the pandemic was associated with longer LOS. It was more difficult to identify a trained caregiver during the pandemic., (Copyright © 2023 by the American Academy of Pediatrics.)

Detecting disparities in health care requires special statistical consideration to assess meaningful differences in exposure, process, or outcome between 2 or more groups on the basis of race, ethnicity, or language. Statistical tests with resulting P values need to be contextualized and thresholds of significance selected carefully before drawing conclusions., (Copyright © 2022 by the American Academy of Pediatrics.)

Objective: To describe associations between the Child Opportunity Index (COI) and multisystem inflammatory syndrome of childhood (MIS-C) diagnosis among hospitalized children., Methods: We used a retrospective case control study design to examine children ≤21 years hospitalized at a single, tertiary care children's hospital between March 2020 and June 2021. Our study population included children diagnosed with MIS-C (n = 111) and a control group of children hospitalized for MIS-C evaluation who had an alternative diagnosis (n = 61). Census tract COI was the exposure variable, determined using the patient's home address mapped to the census tract. Our outcome measure was MIS-C diagnosis. Odds ratios measured associations between COI and MIS-C diagnosis., Results: Our study population included 111 children diagnosed with MIS-C and 61 children evaluated but ruled out for MIS-C. The distribution of census tract overall COI differed significantly between children diagnosed with MIS-C compared with children with an alternate diagnosis (P = .03). Children residing in census tracts with very low to low overall COI (2.82, 95% confidence interval [CI]: 1.29-6.17) and very low to low health/environment COI (4.69, 95% CI 2.21-9.97) had significantly higher odds of being diagnosed with MIS-C compared with children living in moderate and high to very high COI census tracts, respectively., Conclusion: Census tract child opportunity is associated with MIS-C diagnosis among hospitalized children suggesting an important contribution of place-based determinants in the development of MIS-C., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Effective communication between physician and parent promotes a successful alliance with families. The association of parental stress with self-efficacy when communicating during parent-physician interactions is unknown in the context of a pandemic., Objectives: Objectives of this study include quantifying and comparing the stress experienced by parents of hospitalized children before and after onset of the COVID-19 pandemic and examining the relationship of stress with self-efficacy in parent-physician communication during interactions throughout hospitalization., Methods: We conducted in-person surveys of parents of children aged 3 months to 17 years hospitalized at a quaternary-level children's hospital, before and after onset of COVID-19. Parents completed 2 validated tools: Parenting Stress Index (PSI-SF) and the Perceived Efficacy in Parent-Physician Interactions (PEPPI), measuring self-efficacy in communicating with physicians. Socioeconomic data were collected. Fisher exact test and t test were used to compare score proportions and means; linear regression was used to evaluate association between PSI-SF and PEPPI with confounder adjustments., Results: Forty-nine parents were recruited; the majority identified as non-White and female. An inverse relationship was noted between the total stress score and parental self-efficacy, which only attained statistical significance in the post-COVID-19 cohort (P = .02, multivariate P = .044). A significant increase in the mean was observed for subscale scores of Difficult Child (P = .019) and Parent-Child Dysfunctional Interaction after COVID-19 (P = .016)., Conclusions: Elevated parental stress is associated with decreased self-efficacy during parent-physician interactions and it worsened during the pandemic. Future studies should examine the effect of different communication styles on parental stress and self-efficacy during hospitalization., (Copyright © 2022 by the American Academy of Pediatrics.)

Objectives: Describe the prevalence of different care models for children with Kawasaki disease (KD) and evaluate utilization and cardiac outcomes by care model., Methods: Multicenter, retrospective cohort study of children aged 0 to 18 hospitalized with KD in US children's hospitals from 2017 to 2018. We classified hospital model of care via survey: hospitalist primary service with as-needed consultation (Model 1), hospitalist primary service with automatic consultation (Model 2), or subspecialist primary service (Model 3). Additional data sources included administrative data from the Pediatric Health Information System database supplemented by a 6-site chart review. Utilization outcomes included laboratory, medication and imaging usage, length of stay, and readmission rates. We measured the frequency of coronary artery aneurysms (CAAs) in the full cohort and new CAAs within 12 weeks in the 6-site chart review subset., Results: We included 2080 children from 44 children's hospitals; 21 hospitals (48%) identified as Model 1, 19 (43%) as Model 2, and 4 (9%) as Model 3. Model 1 institutions obtained more laboratory tests and had lower overall costs (P < .001), whereas echocardiogram (P < .001) and immune modulator use (P < .001) were more frequent in Model 3. Secondary outcomes, including length of stay, readmission rates, emergency department revisits, CAA frequency, receipt of anticoagulation, and postdischarge CAA development, did not differ among models., Conclusions: Modest cost and utilization differences exist among different models of care for KD without significant differences in outcomes. Further research is needed to investigate primary service and consultation practices for KD to optimize health care value and outcomes., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2022 by the American Academy of Pediatrics.)

Background: Use of intravenous magnesium (IVMg) for childhood asthma exacerbations has increased significantly in the last decade. Emergency department administration of IVMg has been shown to reduce asthma hospitalization, yet most children receiving IVMg in the emergency department are subsequently hospitalized. Our objective with the study was to examine hospital outcomes of children given IVMg for asthma exacerbations., Methods: We conducted a retrospective cohort study using data from the Pediatric Health Information System. We used propensity score matching to compare children who received IVMg on the first day of hospitalization with those who did not. Primary outcomes were initiation and duration of noninvasive positive pressure ventilation. Secondary outcomes included mechanical ventilation (MV) initiation, duration of MV, length of stay, and subsequent tertiary medication use. Primary analysis was restricted to children admitted to nonintensive care inpatient units., Results: Overall, 91 309 hospitalizations met inclusion criteria. IVMg was administered in 25 882 (28.4%) children. After propensity score matching, IVMg was not significantly associated with lower initiation (adjusted odds ratio 0.88; 95% confidence interval [CI] 0.74-1.05) or shorter duration of noninvasive positive pressure ventilation (rate ratio 0.94; 95% CI 0.87-1.02). Similarly, no significant associations were seen for MV initiation, MV duration, or length of stay. IVMg was associated with lower subsequent tertiary medication use (adjusted odds ratio 0.66; 95% CI 0.60-0.72). However, the association was lost when ipratropium was removed from the tertiary medication definition., Conclusions: IVMg administration was not significantly associated with improved hospital outcomes. Further study is needed to inform the optimal indications and timing of magnesium use during hospitalization., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. Our objective was to compare pediatric hospitalization safety events during the pandemic versus previous years., Methods: In this retrospective cohort study of hospitalizations in the Pediatric Health Information System, we compared Pediatric Quality Indicator (PDI) rates from March 15 to May 31, 2017-2019 (pre-COVID-19), with those from March 15 to May 31, 2020 (during COVID-19). Generalized linear mixed-effects models with adjustment for patient characteristics (eg, diagnosis, clinical severity) were used., Results: There were 399 113 discharges pre-COVID-19 and 88 140 during COVID-19. Unadjusted PDI rates were higher during versus pre-COVID-19 for overall PDIs (6.39 vs 5.05; P < .001). In adjusted analyses, odds of postoperative sepsis were higher during COVID-19 versus pre-COVID-19 (adjusted odds ratio 1.28 [95% confidence interval 1.04-1.56]). The remainder of the PDIs did not have increased adjusted odds during compared with pre-COVID-19., Conclusions: Postoperative sepsis rates increased among children hospitalized during COVID-19. Efforts are needed to improve safety of postoperative care for hospitalized children., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Quality improvement (QI) and patient safety are essential to the practice of medicine. Specific training in these fields has become a requirement in graduate medical education, although there is great variation in how residency programs choose to approach trainee education in QI and patient safety. Residents have a unique vantage point into the operations of a health care system and can guide the development of system improvement initiatives. In this report, we (1) describe the context that led to the creation of a pediatric resident safety council (PRSC) in its current structure, (2) identify the organizational features implemented to best meet the objectives of this council, and (3) describe the local and institutional impact of the PRSC. A PRSC is a useful model to build resident engagement in safe and high-quality patient care within a residency program and health care system. A PRSC encourages the professional development of future pediatric safety leaders and facilitates experiential training in patient safety and QI science., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2021 by the American Academy of Pediatrics.)

Background: Little is known about what hospital and emergency department (ED) factors predict performance in pediatric quality improvement efforts., Objectives: Identify site characteristics and implementation strategies associated with improvements in pediatric asthma care., Methods: In this secondary analysis, we used data from a national quality collaborative. Data on site factors were collected via survey of implementation leaders. Data on quality measures were collected via chart review of children with a primary diagnosis of asthma. ED measures included severity assessment at triage, corticosteroid administration within 60 minutes, avoidance of chest radiographs, and discharge from the hospital. Inpatient measures included early administration of bronchodilator via metered-dose inhaler, screening for tobacco exposure, and caregiver referral to smoking cessation resources. We used multilevel regression models to determine associations between site factors and changes in mean compliance across all measures., Results: Sixty-four EDs and 70 inpatient units participated. Baseline compliance was similar by site characteristics. We found significantly greater increases in compliance in EDs within nonteaching versus teaching hospitals (12% vs 5%), smaller versus larger hospitals (10% vs 4%), and rural and urban versus suburban settings (6%-7% vs 3%). In inpatient units, we also found significantly greater increases in compliance in nonteaching versus teaching hospitals (36% vs 17%) and community versus children's hospitals (23% vs 14%). Changes in compliance were not associated with organizational readiness or number of audit and feedback sessions or improvement cycles., Conclusions: Specific hospital and ED characteristics are associated with improvements in pediatric asthma care. Identifying setting-specific barriers may facilitate more targeted implementation support., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Gun violence is a US public health crisis. Approximately 7000 children are hospitalized each year because of firearm-related injuries. As pediatric hospitalists, we are poised to address this crisis, whether we care directly for patients who are victims of gun violence. In this article, we aim to provide practical tools and opportunities for pediatric hospitalists to address the epidemic of gun safety and gun violence prevention, including specifics related to the inpatient setting. We provide a framework to act within 4 domains: clinical care, advocacy, education and research., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Stakeholder engagement is emerging as a tool for clinician investigators to learn from patients, families, and health professionals to better design and implement interventions that are responsive to patient and family needs and preferences. In this article, we demonstrate that multidisciplinary stakeholder engagement can meaningfully influence intervention design. We present a model of efficient yet substantive engagement of parents and health professionals in developing a hospital-to-home transition intervention for children hospitalized with asthma. We engaged parents during the acute hospitalization with one-on-one interviews, and we used one-on-one interviews and focus groups to engage key health professionals to facilitate meaningful engagement. We worked with a group of selected parent advisory council members (composed of parents of children with asthma) to refine the information gained from the parents and health professionals. We found that multidimensional stakeholder engagement can meaningfully shape intervention development, and we hope that these tools can be used or adapted to other hospital-based quality improvement, education, or research efforts., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2019 by the American Academy of Pediatrics.)

Objectives: To develop a comprehensive understanding of the barriers and/or facilitators for asthma management for the health professionals and caregivers of children with >1 hospitalization., Methods: Individual interviews were conducted with family caregivers and health professionals. Focus groups were conducted with school nurses. The interview and focus group guide were used to probe for barriers and facilitators of asthma management. Interviews were recorded, transcribed, and coded by using qualitative software. Themes were identified by using content analysis in the interviews and descriptive qualitative analysis in the focus groups., Results: Caregivers ( n = 10), asthma educators ( n = 4), physicians ( n = 4), and a payer ( n = 1) were individually interviewed. School nurses were interviewed via a focus group ( n = 10). Children had a median age of 7 years, mean length of stay of 1.9 days, and 56% had a previous hospitalization in the previous 12 months. The "gaps in asthma knowledge" theme (which includes an inadequate understanding of asthma chronicity, activity restrictions, and management with controller medications) emerged as a theme for both caregivers and health professionals but with different health beliefs. School nurses reinforced the difficulty they have in managing children who have asthma in schools, and they identified using the asthma action plan as a facilitator., Conclusions: Caregivers and health professionals have different health beliefs about asthma knowledge, which raises challenges in the care of a child who has asthma. In addition, school nurses highlight specific barriers that are focused on medication use in schools. A comprehensive understanding of the barriers and facilitators of asthma management that families experience after hospital discharge is crucial to design better efforts to support families., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2018 by the American Academy of Pediatrics.)

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Pediatric firearm-related deaths and injuries are a national public health crisis. In this Special Review Article, we characterize the epidemiology of firearm-related injuries in the United States and discuss public health programs, the role of pediatricians, and legislative efforts to address this health crisis. Firearm-related injuries are leading causes of unintentional injury deaths in children and adolescents. Children are more likely to be victims of unintentional injuries, the majority of which occur in the home, and adolescents are more likely to suffer from intentional injuries due to either assault or suicide attempts. Guns are present in 18% to 64% of US households, with significant variability by geographic region. Almost 40% of parents erroneously believe their children are unaware of the storage location of household guns, and 22% of parents wrongly believe that their children have never handled household guns. Public health interventions to increase firearm safety have demonstrated varying results, but the most effective programs have provided free gun safety devices to families. Pediatricians should continue working to reduce gun violence by asking patients and their families about firearm access, encouraging safe storage, and supporting firearm-related injury prevention research. Pediatricians should also play a role in educating trainees about gun violence. From a legislative perspective, universal background checks have been shown to decrease firearm homicides across all ages, and child safety laws have been shown to decrease unintentional firearm deaths and suicide deaths in youth. A collective, data-driven public health approach is crucial to halt the epidemic of pediatric firearm-related injury., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2017 by the American Academy of Pediatrics.)

Objectives: This study describes blood culture collection rates, results, and microbiology laboratory charges for 4 leading pediatric inpatient diagnoses (asthma, bronchiolitis, pneumonia, and skin and soft tissue infection [SSTI]) in low-risk patients., Methods: This retrospective cohort study was conducted at an urban, academic, quaternary children's hospital. The study period was from January 1, 2011, to December 31, 2011. Inclusion criteria were as follows: 6 months to 18 years of age and primary diagnosis of asthma (International Classification of Diseases, Ninth Revision [ICD-9] codes 493.91-493.92), bronchiolitis (ICD-9 codes 466.11 and 466.19), SSTI (ICD-9 codes 680.00-686.99), or pneumonia (community-acquired pneumonia; ICD-9 codes 481.00-486.00). Patients with complex chronic conditions were excluded. Data were collected via administrative billing data and chart review. Descriptive statistics were performed; χ(2) tests were used for categorical variables, and nonparametric tests were used for continuous variables because of non-normal distributions., Results: Administrative data review included 5159 encounters, with 1629 (32%) inpatient encounters and 3530 (68%) emergency department/outpatient encounters. Twenty-one percent (n = 343) of inpatient encounters had blood cultures performed, whereas 3% (n = 111) of emergency department/outpatient encounters had blood culture testing performed. Inpatient blood culture utilization varied according to diagnosis: asthma, 4%; bronchiolitis, 15%; pneumonia, 36%; and SSTI, 46%. Charts were reviewed for all 343 inpatients with blood culture testing. Results of all the blood cultures obtained for asthma and bronchiolitis admissions were negative, with 98% and 99% negative or false-positive (contaminant) for SSTI and community-acquired pneumonia, respectively. The approximate financial impact of blood culture utilization (according to gross microbiology laboratory charges) approximated $100 000 over the year for all 4 diagnoses., Conclusions: There was a high rate of negative or false-positive blood culture results for these common inpatient diagnoses. In addition, there was a low rate of clinically significant true-positive (pathogenic) culture results. These results identify points of potential blood culture overutilization.

Objective: Approximately 10% to 15% of Kawasaki disease (KD) is refractory to treatment with initial intravenous immunoglobulin (IVIG). However, there is no consensus on pharmacologic treatment of refractory KD (rKD). Demographic characteristics of patients with rKD and regional variability in their treatment in the United States have not been reported on a large scale. The goal of this study was to describe the demographic and treatment variability in rKD by using a large multi-institutional database., Methods: Data were obtained for patients with KD from January 2005 to June 2009 by using the Pediatric Health Information System. Patients who received a single dose of IVIG were labeled as having standard KD (sKD) and those who required additional medications were labeled as having rKD., Results: Of the 5633 patients studied, 4818 (85.5%) received 1 dose of IVIG (sKD) and 815 (14.5%) received >1 medication (rKD). Median age was 30 months (interquartile range: 14-53) and 30 months (interquartile range: 15-54) for rKD and sKD patients, respectively (P= .438). No significant change was noted in the gender or ethnic distribution of patients between rKD and sKD groups. Seasonal distribution of rKD was comparable to sKD. IVIG was the most common (64.5%) initial medication chosen to treat rKD, followed by methylprednisolone (27.1%) and infliximab (8.3%); however, there was significant regional variability. Of patients with rKD, 81% required only 1 additional medication (after the initial IVIG) for treatment., Conclusions: Patients with rKD have similar age, gender, ethnic, and seasonal distribution as sKD patients. IVIG is the most common initial medication chosen to treat rKD; however, there is regional variation.