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Background: Return visits (RVs) and RVs with admission (RVAs) are commonly used emergency department quality measures. Visit- and patient-level factors, including several social determinants of health, have been associated with RV rates, but hospital-specific factors have not been studied., Objective: To identify what hospital-level factors correspond with high RV and RVA rates., Setting: Multicenter mixed-methods study of hospital characteristics associated with RV and RVA rates., Data Source: Pediatric Health Information System with survey of emergency department directors., Measurements: Adjusted return rates were calculated with generalized linear mixed-effects models. Hospitals were categorized by adjusted RV and RVA rates for analysis., Results: Twenty-four hospitals accounted for 1,456,377 patient visits with an overall adjusted RV rate of 3.7% and RVA rate of 0.7%. Hospitals with the highest RV rates served populations that were more likely to have government insurance and lower median household incomes and less likely to carry commercial insurance. Hospitals in the highest RV rate outlier group had lower pediatric emergency medicine specialist staffing, calculated as full-time equivalents per 10,000 patient visits: median (interquartile range) of 1.9 (1.5-2.1) versus 2.9 (2.2-3.6). There were no differences in hospital population characteristics or staffing by RVA groups., Conclusion: RV rates were associated with population social determinants of health and inversely related to staffing. Hospital-level variation may indicate population-level economic factors outside the control of the hospital and unrelated to quality of care., (© 2017 Society of Hospital Medicine)

Background: Hospitalizations of children with medical complexity (CMC) account for one-half of hospital days in children, with lengths of stays (LOS) that are typically longer than those for children without medical complexity. The objective was to assess the impact of, risk factors for, and variation across children's hospitals regarding long LOS (≥10 days) hospitalizations in CMC., Methods: A retrospective study of 954,018 CMC hospitalizations, excluding admissions for neonatal and cancer care, during 2013 to 2014 in 44 children's hospitals. CMC were identified using 3M's Clinical Risk Group categories 6, 7, and 9, representing children with multiple and/or catastrophic chronic conditions. Multivariable regression was used to identify demographic and clinical characteristics associated with LOS ≥10 days. Hospital-level risk-adjusted rates of long LOS generated from these models were compared using a covariance test of the hospitals' random effect., Results: Among CMC, LOS ≥10 days accounted for 14.9% (n = 142,082) of all admissions and 61.8% ($13.7 billion) of hospital costs. The characteristics most strongly associated with LOS ≥10 days were use of intensive care unit (ICU) (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.4-3.5), respiratory complex chronic condition (OR: 2.7, 95% CI: 2.6-2.7), and transfer from another medical facility (OR: 2.1, 95% CI: 2.0-2.1). After adjusting for severity, there was significant (P < 0.001) variation in the prevalence of LOS ≥10 days for CMC across children's hospitals (range, 10.3%-21.8%)., Conclusions: Long hospitalizations for CMC are costly. Their prevalence varies significantly by type of chronic condition and across children's hospitals. Efforts to reduce hospital costs in CMC might benefit from a focus on prolonged LOS. Journal of Hospital Medicine 2016;11:750-756. © 2016 Society of Hospital Medicine., (© 2016 Society of Hospital Medicine.)

Background: Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs., Objective: Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants., Design: Retrospective cross-sectional study in 2013., Setting: Thirty-three hospitals in the Pediatric Health Information System., Patients: Infants aged ≤56 days with a diagnosis of fever., Exposures: The presence and content of ED-based febrile infant CPGs assessed by electronic survey., Measurements: Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs., Results: We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs., Conclusions: CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs., (© 2015 Society of Hospital Medicine.)

Background: Pediatric observation units (OUs) have demonstrated reductions in lengths of stay (LOS) and costs of care. Hospital-level outcomes across all observation-status stays have not been evaluated in relation to the presence of a dedicated OU in the hospital., Objective: To compare observation-status stay outcomes in hospitals with and without a dedicated OU., Design: Cross-sectional analysis of hospital administrative data., Methods: Observation-status stay outcomes were compared in hospitals with and without a dedicated OU across 4 categories: (1) LOS, (2) standardized costs, (3) conversion to inpatient status, and (4) return care., Setting/patients: Observation-status stays in 31 free-standing children's hospitals contributing observation patient data to the Pediatric Health Information System database, 2011., Results: Fifty-one percent of the 136,239 observation-status stays in 2011 occurred in 14 hospitals with a dedicated OU; the remainder were in 17 hospitals without. The percentage of observation-status same-day discharges was higher in hospitals with a dedicated OU compared with hospitals without (23.8 vs 22.1, P < 0.001), but risk-adjusted LOS in hours and total standardized costs were similar. Conversion to inpatient status was higher in hospitals with a dedicated OU (11.06%) compared with hospitals without (9.63%, P < 0.01). Adjusted odds of return visits and readmissions were comparable., Conclusions: The presence of a dedicated OU appears to have an influence on same-day and morning discharges across all observation-status stays without impacting other hospital-level outcomes. Inclusion of location of care (eg, dedicated OU, inpatient unit, emergency department) in hospital administrative datasets would allow for more meaningful comparisons of models of hospital care., (© 2015 Society of Hospital Medicine.)

Comanagement of surgical patients is occurring more commonly among adult and pediatric patients. These systems of care can vary according to institution type, comanagement structure, and type of patient. Comanagement can impact quality, safety, and costs of care. We review these implications for pediatric surgical patients., (© 2014 Society of Hospital Medicine.)

Background: This program evaluation sought to compare cost and pediatric patient outcomes among a pediatric nurse practitioner (PNP) hospitalist team, a combined PNP/doctor of medicine (MD) team, and 2 resident teams without PNPs., Methods: Administrative and electronic medical record data from July 1, 2009 to June 30, 2010 was retrospectively reviewed from Children's Hospital Colorado inpatient medical unit and inpatient satellite sites in the Children's Hospital network of care (NOC). The top 3 All Patient Refined Diagnosis Related Groups (APR-DRG) admission codes bronchiolitis and respiratory syncytial virus (RSV) pneumonia, pneumonia not elsewhere classified (NEC), and asthma were selected for this analysis. Inpatient records representing these APR-DRG admission codes were reviewed (N = 1664). Measures included adherence with relevant clinical care guidelines (CCGs), length of stay (LOS), and cost of care. Chi square, t tests, and analysis of variance were used to analyze between-group differences., Results: Approximately 20% of these admissions were on the PNP team, 45% were on the resident teams, and 35% were on the PNP/MD team in the NOC. PNP adherence to CCGs was comparable to resident teams for selected measures. There was no significant difference in LOS among the PNP team, the PNP/MD team, and the resident teams. The direct cost of patient care per encounter provided by the PNP team was significantly less than the PNP/MD team and the resident teams., Conclusions: There is evidence to suggest that PNP hospitalists provide inpatient care comparable to resident teams at a lower cost for patients with uncomplicated bronchiolitis, pneumonia, and asthma., (© 2014 Society of Hospital Medicine.)

Background: Many pediatric academic centers have hospital medicine programs. Anecdotal data suggest that variability exists in program structure., Objective: To provide a description of the organizational, administrative, and financial structures of academic pediatric hospital medicine (PHM)., Methods: This online survey focused on the organizational, administrative, and financial aspects of academic PHM programs, which were defined as hospitalist programs at US institutions associated with accredited pediatric residency program (n = 246) and identified using the Accreditation Council for Graduate Medical Education (ACGME) Fellowship and Residency Electronic Interactive Database. PHM directors and/or residency directors were targeted by both mail and the American Academy of Pediatrics Section on Hospital Medicine LISTSERV., Results: The overall response rate was 48.8% (120/246). 81.7% (98/120) of hospitals reported having an academic PHM program, and 9.1% (2/22) of hospitals without a program reported plans to start a program in the next 3 years. Over a quarter of programs provide coverage at multiple sites. Variability was identified in many program factors, including hospitalist workload and in-house coverage provided. Respondents reported planning increased in-house hospitalist coverage coinciding with the 2011 ACGME work-hour restrictions. Few programs reported having revenues greater than expenses (26% single site, 4% multiple site)., Conclusions: PHM programs exist in the majority of academic centers, and there appears to be variability in many program factors. This study provides the most comprehensive data on academic PHM programs and can be used for benchmarking as well as program development., (Copyright © 2013 Society of Hospital Medicine.)

Background: Pediatric hospitalist systems are increasing in popularity, but data regarding the effects of hospitalist systems on the quality of care has been sparse, in part because rigorous metrics for analysis have not yet been established. We conducted a literature review of studies comparing the performance of pediatric hospitalists and traditional attendings., Objective: To determine the effect of pediatric hospitalists on quality and outcome metrics such as length of stay, cost, patient satisfaction, mortality, readmission rates, and use of evidence-based medicine during care., Results: A Medline literature search identified 11 studies that met criteria for inclusion. Five previously reviewed studies reported lengths of stay between 6% and 14% shorter for hospitalists. Five of the new studies evaluated lengths of stay, with 1 showing significantly lower length of stay and cost for a faculty model, 1 showing lower length of stay for hospitalists for all conditions, 1 for certain conditions only, and 2 showing no statistical difference. Six studies reported on readmission rate, with 4 showing no difference, 1 showing decreased readmissions for hospitalists, and 1 showing decreased readmissions for a traditional faculty service. Hospitalists self-report higher use of evidence-based guidelines. Few differences in patient satisfaction were reported. Mortality on the pediatrics wards is rare, and no studies were adequately powered to evaluate mortality rate., Conclusion: Hospitalists can improve the quality and efficiency of inpatient care in the pediatric population, but the effect is not universal, and mechanisms underlying demonstrated improvements are poorly understood. We propose 4 components to improve quality and value in hospital medicine systems: investment in comparative effectiveness research involving delivery system interventions, development and implementation of pediatric quality measures, better understanding of improvement mechanisms for hospital medicine systems, and increased focus on quality and value delivered by hospital medicine groups and individuals., (Copyright © 2011 Society of Hospital Medicine.)

Objective: To define the epidemiology of systemic complications and focal infections associated with bacterial meningitis and quantify how the presence of such complications affects in-hospital healthcare resource utilization., Methods: Retrospective cohort study using administrative data from 27 children's hospitals. Children <18 years of age diagnosed with bacterial meningitis from 2001 to 2006 were eligible. The primary exposure of interest was the presence of a bacterial meningitis-associated condition, classified as either systemic complications (eg, sepsis), associated focal infections (eg, pneumonia) or both. The primary outcomes were total in-hospital charges and length of stay (LOS)., Results: A total of 574 of 2319 (25%) of children had a systemic complication or an associated focal infection. Compared with children without complications, in-hospital charges were significantly higher in children with systemic complications (136% increase), associated focal infections (118% increase), and both conditions (351% increase). LOS was also significantly increased in those with systemic complications (by 72%), associated focal infections (by 78%), or both conditions (by 211%). The presence of systemic complications was more common in younger children while the presence of an associated focal infection was more common in older children., Conclusions: Children with bacterial meningitis often have additional morbidity due to systemic complications or associated focal infections indicated by increase use of acute in-hospital resource utilization. The apparent increase in in-hospital morbidity related to these conditions should be considered in future evaluations of vaccine efficacy, novel therapeutics, and hospital resource allocation., ((c) 2010 Society of Hospital Medicine.)

Background: Delays in discharges affect both efficiency and timeliness of care; 2 measures of quality of inpatient care., Objective: Describe number, length, and type of delays in hospital discharges. Characterize impact of delays on overall length of stay (LOS) and costs., Design: Prospective observational cohort study., Setting: Tertiary-care children's hospital., Patients: All children on 2 medical teams during August 2004., Intervention: Two research assistants presented detailed data of patient care (from daily rounds) to 2 physicians who identified delays and classified the delay type. Discharge was identified as delayed if there was no medical reason for the patient to be in the hospital on a given day., Measurements: Delays were classified using a validated and reliable instrument, the Delay Tool. LOS and costs were extracted from an administrative database., Results: Two teams cared for 171 patients. Mean LOS and costs were 7.3 days (standard deviation [SD] 14.3) and $15,197 (SD 38,395), respectively: 22.8% of patients experienced at least 1 delay, accounting for 82 delay-related hospital days (9% of total hospital days) and $170,000 in costs (8.9% of hospital costs); 42.3% of the delays resulted from physician behavior, 21.8% were related to discharge planning, 14.1% were related to consultation, and 12.8% were related to test scheduling., Conclusions: Almost one-fourth of patients in this 1-month period could have been discharged sooner than they were. Impact of delays on LOS and costs are substantial. Interventions will need to address variations in physician criteria for discharge, more efficient discharge planning, and timely scheduling of consultation and diagnostic testing., (Copyright 2009 Society of Hospital Medicine)

Objective: To use hospitalization data from 2003 to determine whether prior findings, showing higher charges and longer lengths-of-stay (LOSs) for children with obesity versus those without, were stable over time and whether the magnitude of differences was consistent over a 4-year period., Methods: Using the 2000 and 2003 Agency for Healthcare Research and Quality (AHRQ) Kids Inpatient Database (KID), we examined discharges for the top 4 nonpregnancy-related principal discharge diagnoses for children aged 2-18 years (asthma, pneumonia, affective disorders, and appendicitis), classified as with or without obesity based on the presence of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 278.0x as a secondary diagnosis. We compared mean charges for hospitalizations with obesity listed as secondary diagnosis versus those without. Results are presented in 2003 dollars., Results: Among children's discharges in 2000 and 2003, 1.1% and 1.6%, respectively, listed obesity as a secondary diagnosis. In 2003, for all 4 diagnoses, adjusted mean hospital charges were statistically significantly higher and adjusted mean LOS was statistically significantly longer for discharges with obesity as a secondary diagnosis versus those without. Additionally, the magnitude of the differences for both charges and LOS was generally somewhat greater in 2003 than in 2000 (asthma 9%, pneumonia 17%, affective disorders 121%, and appendicitis 3%) although it did not achieve statistical significance (P > 0.05)., Conclusions: These findings suggest a widening gap of incremental charges and LOS associated with obesity as a comorbidity. This implies a financial imperative for further research to evaluate factors that contribute to greater resource utilization among obese children., ((c) 2009 Society of Hospital Medicine.)