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IMPORTANCE: Children with medical complexity (CMC) have substantial health care needs and frequently experience poor health care quality. Understanding the population prevalence and associated health care needs can inform clinical and public health initiatives. OBJECTIVE: To estimate the prevalence of CMC using open-source pediatric algorithms, evaluate performance of these algorithms in predicting health care utilization and in-hospital mortality, and identify associations between medical complexity as defined by these algorithms and clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used all-payer claims data from Colorado, Massachusetts, and New Hampshire from 2012 through 2017. Children and adolescents younger than 18 years residing in these states were included if they had 12 months or longer of enrollment in a participating health care plan. Analyses were conducted from March 12, 2021, to January 7, 2022. EXPOSURES: The pediatric Complex Chronic Condition Classification System, Pediatric Medical Complexity Algorithm, and Children With Disabilities Algorithm were applied to 3 years of data to identify children with complex and disabling conditions, first in their original form and then using more conservative criteria that required multiple health care claims or involvement of 3 or more body systems. MAIN OUTCOMES AND MEASURES: Primary outcomes, examined over 2 years, included in-hospital mortality and a composite measure of health care services, including specialized therapies, specialized medical equipment, and inpatient care. Outcomes were modeled using logistic regression. Model performance was evaluated using C statistics, sensitivity, and specificity. RESULTS: Of 1 936 957 children, 48.4% were female, 87.8% resided in urban core areas, and 45.1% had government-sponsored insurance as their only primary payer. Depending on the algorithm and coding criteria applied, 0.67% to 11.44% were identified as CMC. All 3 algorithms had adequate discriminative ability, sensitivity, and specificity to predict in-hospital mortality and composite health care services (C statistic = 0.76 [95% CI, 0.73-0.80] to 0.81 [95% CI, 0.78-0.84] for mortality and 0.77 [95% CI, 0.76-0.77] to 0.80 [95% CI, 0.79-0.80] for composite health care services). Across algorithms, CMC had significantly greater odds of mortality (adjusted odds ratio [aOR], 9.97; 95% CI, 7.70-12.89; to aOR, 69.35; 95% CI, 52.52-91.57) and composite health care services (aOR, 4.59; 95% CI, 4.44-4.73; to aOR, 18.87; 95% CI, 17.87-19.93) than children not identified as CMC. CONCLUSIONS AND RELEVANCE: In this study, open-source algorithms identified different cohorts of CMC in terms of prevalence and magnitude of risk, but all predicted increased health care utilization and in-hospital mortality. These results can inform research, programs, and policies for CMC.

OBJECTIVEThe primary objective of this study was to use the prospective Hydrocephalus Clinical Research Network (HCRN) registry to determine clinical predictors of fast time to shunt failure (≤ 30 days from last revision) and ultrafast time to failure (≤ 7 days from last revision).METHODSRevisions (including those due to infection) to permanent shunt placements that occurred between April 2008 and November 2017 for patients whose entire shunt experience was recorded in the registry were analyzed. All registry data provided at the time of initial shunt placement and subsequent revision were reviewed. Key variables analyzed included etiology of hydrocephalus, age at time of initial shunt placement, presence of slit ventricles on imaging at revision, whether the ventricles were enlarged at the time of revision, and presence of prior fast failure events. Univariable and multivariable analyses were performed to find key predictors of fast and ultrafast failure events.RESULTSA cohort of 1030 patients with initial shunt insertions experienced a total of 1995 revisions. Of the 1978 revision events with complete records, 1216 (61.5%) shunts remained functional for more than 1 year, and 762 (38.5%) failed within 1 year of the procedure date. Of those that failed within 1 year, 423 (55.5%) failed slowly (31–365 days) and 339 (44.5%) failed fast (≤ 30 days). Of the fast failures, 131 (38.6%) were ultrafast (≤ 7 days). In the multivariable analysis specified a priori, etiology of hydrocephalus (p = 0.005) and previous failure history (p = 0.011) were independently associated with fast failure. Age at time of procedure (p = 0.042) and etiology of hydrocephalus (p = 0.004) were independently associated with ultrafast failure. These relationships in both a priori models were supported by the data-driven multivariable models as well.CONCLUSIONSNeither the presence of slit ventricle syndrome nor ventricular enlargement at the time of shunt failure appears to be a significant predictor of repeated, rapid shunt revisions. Age at the time of procedure, etiology of hydrocephalus, and the history of previous failure events seem to be important predictors of fast and ultrafast shunt failure. Further work is required to understand the mechanisms of these risk factors as well as mitigation strategies.

OBJECTIVES: To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis. METHODS: We prospectively enrolled children with bronchiolitis at 5 children’s hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 “overuse” indicators for care that should not occur and 7 “underuse” indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital. RESULTS: We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: −24.3 hours; adjusted mean cost difference: −$731, P < .001), no complete blood cell counts (LOS: −17.8 hours; cost: −$399, P < .05), and no respiratory syncytial virus testing (LOS: −16.6 hours; cost: −$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05). CONCLUSIONS: A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.

OBJECTIVES: To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses. METHODS: We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models. RESULTS: Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference −0.3; 95% confidence interval: −1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (−4.6; 95% confidence interval: −7.5 to −1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status. CONCLUSIONS: We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians “do more” for hospitalized children who are not UTD.

Despite a growing population of children with medical complexity, little is known about the current quality of pediatric home healthcare. The objective of this study was to characterize the quality of pediatric home healthcare experienced by primary family caregivers (parents) and healthcare providers of children with medical complexity. Semi-structured, in-depth key informant interviews of 20 caregivers and 20 providers were conducted and analyzed for factors affecting home healthcare quality using the Institute of Medicine’s quality framework (effective, safe, patient-centered, timely, equitable, and efficient). System complexity, insurance denials, and workforce shortages affected patients’ ability to establish and maintain access to home healthcare leading to hospital discharge delays and negative family impacts. When home healthcare was accessible, respondents experienced it as effective in improving patient and family daily life and minimizing use of emergency and hospital services. However, respondents identified a need for more pediatric-specific home healthcare training and increased efficiencies in care plan communication. Overall, home healthcare was not perceived as timely or equitable due to access barriers. This study provides a new conceptual framework representing the relationship between home healthcare quality and outcomes for children with medical complexity for future evaluations of quality improvement, research, and policy initiatives.

BACKGROUND: Up to 90% of children develop Pseudomonas aeruginosa (Pa)-positive respiratory cultures after tracheotomy. OBJECTIVE: To identify factors associated with chronic Pa-positive respiratory cultures in the first two years after tracheotomy. METHOD: We conducted a retrospective cohort study of 210 children ≤18 years old who underwent tracheotomy at a single freestanding children’s hospital who had two or more years of respiratory cultures post-tracheotomy available for analysis. We conducted multivariable logistic regression to test the association between demographic and clinical factors to our primary outcome of chronic Pa infection, defined as >75% of respiratory cultures positive for Pa in the first two years after tracheotomy. RESULTS: Of the primarily male (61%), Hispanic (68%) and publicly-insured (88%) cohort, 18% (n=37) developed chronic Pa-positive respiratory cultures in the first two years. On multivariable logistic regression, pre-tracheotomy Pa-positive respiratory culture (aOR=11.3; 95% CI: 4-1.5) and discharge on beta-agonist (aOR=6.3; 95% CI: 1.1-36.8) were independently associated with chronic Pa-positive respiratory cultures while discharge on chronic mechanical ventilation was associated with decreased odds (aOR=0.3; 95% CI: 0.1-0.7). On sensitivity analysis examining those without a pre-tracheotomy Pa-positive respiratory culture, discharge on MV continued to be associated with decreased odds of chronic Pa (aOR 0.1; 95% CI 0.02-0.4) and three other variables (male gender, chronic lung disease, discharge on inhaled corticosteroids) were associated with increased odds of chronic Pa. CONCLUSION: Because pre-tracheotomy Pa growth on respiratory culture is associated with post-tracheotomy chronic Pa-positive respiratory cultures, future research should examine pre-tracheotomy Pa eradication or suppression protocols.

OBJECTIVEInfection is a common complication of cerebrospinal fluid (CSF) shunts, occurring in 6%–20% of children. Although studies are limited, Staphylococcus aureus is thought to cause more rapid and aggressive infection than coagulase-negative Staphylococcus (CONS) or gram-negative organisms. The authors’ objective was to evaluate the relationship between the causative organisms of CSF shunt infection and the timing of infection.METHODSThe authors performed a retrospective cohort study of children who underwent CSF shunt placement at a tertiary care children’s hospital over a 9-year period and subsequently developed a CSF shunt infection. The primary predictor variable was the causative organism recovered from CSF culture, characterized as S. aureus, CONS, or gram-negative organisms. The primary outcome was time to infection, defined as the number of days from most recent shunt intervention to the diagnosis of the infection. The association between causative organism and time to infection was visualized using Kaplan-Meier curves, and statistical comparisons were made using nonparametric Kruskal-Wallis tests.RESULTSAmong 103 children in whom a CSF shunt infection developed, the causative organism was CONS in 57 (55%), S. aureus in 19 (18%), and gram-negative organisms in 9 (9%). The median time to infection did not differ (p = 0.81) for infections caused by CONS (20 days, IQR 11–40), S. aureus (26 days, IQR 12–95), and gram-negative organisms (23 days, IQR 17–34).CONCLUSIONSNo significant difference in time to infection based on the causative organism was observed among children with a CSF shunt infection.

OBJECTIVES:To evaluate the association between caregiver-reported social determinants of health (SDOH) and emergency department (ED) visits and hospitalizations by children with chronic disease.METHODS:This was a nested retrospective cohort study (December 2015 to May 2017) of children (0–18 years) receiving Supplemental Security Income and Medicaid enrolled in a case management program. Caregiver assessments were coded for 4 SDOH: food insecurity, housing insecurity, caregiver health concerns, and safety concerns. Multivariable hurdle Poisson regression was used to assess the association between SDOH with ED and hospital use for 1 year, adjusting for age, sex, and race and ethnicity. ED use was also adjusted for medical complexity.RESULTS:A total of 226 children were included. Patients were 9.1 years old (SD: 4.9), 60% male, and 30% Hispanic. At least 1 SDOH was reported by 59% of caregivers, including food insecurity (37%), housing insecurity (23%), caregiver health concerns (18%), and safety concerns (11%). Half of patients had an ED visit (55%) (mean: 1.5 per year [SD: 2.4]), and 20% were hospitalized (mean: 0.4 per year [SD: 1.1]). Previously unaddressed food insecurity was associated with increased ED use in the subsequent year (odds ratio: 3.43 [1.17–10.05]). Among those who had ≥1 ED visit, the annualized ED rate was higher in patients with a previously unaddressed housing insecurity (rate ratio: 1.55 [1.14–2.09]) or a safety concern (rate ratio: 2.04 [1.41–2.96]).CONCLUSIONS:Over half of caregivers of children with chronic disease enrolled in a case management program reported an SDOH insecurity or concern. Patients with previously unaddressed food insecurity had higher ED rates but not hospitalization rates.

OBJECTIVEAnalysis of temporal trends in patient populations and procedure types may provide important information regarding the evolution of hydrocephalus treatment. The purpose of this study was to use the Hydrocephalus Clinical Research Network’s Core Data Project to identify meaningful trends in patient characteristics and the surgical management of pediatric hydrocephalus over a 9-year period.METHODSThe Core Data Project prospectively collected patient and procedural data on the study cohort from 9 centers between 2008 and 2016. Logistic and Poisson regression were used to test for significant temporal trends in patient characteristics and new and revision hydrocephalus procedures.RESULTSThe authors analyzed 10,149 procedures in 5541 patients. New procedures for hydrocephalus (shunt or endoscopic third ventriculostomy [ETV]) decreased by 1.5%/year (95% CI −3.1%, +0.1%). During the study period, new shunt insertions decreased by 6.5%/year (95% CI −8.3%, −4.6%), whereas new ETV procedures increased by 12.5%/year (95% CI 9.3%, 15.7%). Revision procedures for hydrocephalus (shunt or ETV) decreased by 4.2%/year (95% CI −5.2%, −3.1%), driven largely by a decrease of 5.7%/year in shunt revisions (95% CI −6.8%, −4.6%). Concomitant with the observed increase in new ETV procedures was an increase in ETV revisions (13.4%/year, 95% CI 9.6%, 17.2%). Because revisions decreased at a faster rate than new procedures, the Revision Quotient (ratio of revisions to new procedures) for the Network decreased significantly over the study period (p = 0.0363). No temporal change was observed in the age or etiology characteristics of the cohort, although the proportion of patients with one or more complex chronic conditions significantly increased over time (p = 0.0007).CONCLUSIONSOver a relatively short period, important changes in hydrocephalus care have been observed. A significant temporal decrease in revision procedures amid the backdrop of a more modest change in new procedures appears to be the most notable finding and may be indicative of an improvement in the quality of surgical care for pediatric hydrocephalus. Further studies will be directed at elucidation of the possible drivers of the observed trends.

OBJECTIVES: Parents frequently decline the influenza vaccine for their child during hospitalization. In this study, we aimed to assess the role of vaccine hesitancy in these declinations. METHODS: This cross-sectional survey study was conducted among English-speaking parents of influenza vaccine-eligible children who were hospitalized between October 2014 and April 2015. Between July 2015 and September 2015, parents were recruited via mail to complete the validated Parent Attitudes about Childhood Vaccines (PACV) survey (modified for influenza vaccination). PACV scores (0–100 scale) were dichotomized into scores of ≥50 (hesitant) and RESULTS: Of 199 parents (18% response rate), 24% were vaccine hesitant and 53% declined the influenza vaccine for their child during hospitalization. Vaccine hesitancy (versus nonhesitancy) was associated with declining influenza vaccination (adjusted odds ratio: 6.4; 95% confidence interval: 2.5–16.5). The declination reason differed by vaccine hesitancy status, with a higher proportion of parents who were hesitant versus nonhesitant reporting “vaccine concern” or “vaccine unnecessary.” CONCLUSIONS: Vaccine hesitancy was prevalent in this limited sample of parents of hospitalized children and associated with influenza vaccine declination. Additional investigation in a large, diverse, prospectively recruited cohort is warranted given the potential sampling bias present in this study.

Background Previous studies of cerebrospinal fluid (CSF) shunt infection treatment have been limited in size and unable to compare patient and treatment characteristics by infecting organism. Our objective was to describe variation in patient and treatment characteristics for children with first CSF shunt infection, stratified by infecting organism subgroups outlined in the 2017 Infectious Disease Society of America’s (IDSA) guidelines. Methods We studied a prospective cohort of children Results There were 145 children whose infections were diagnosed by CSF culture and addressed by IDSA guidelines, including 47 with Staphylococcus aureus, 52 with coagulase-negative Staphylococcus, 37 with Gram-negative bacilli, and 9 with Propionibacterium acnes. No differences in many patient and treatment characteristics were seen between infecting organism subgroups, including age at initial shunt, gender, race, insurance, indication for shunt, gastrostomy, tracheostomy, ultrasound, and/or endoscope use at all surgeries before infection, or numbers of revisions before infection. A larger proportion of infections were caused by Gram-negative bacilli when antibiotic-impregnated catheters were used at initial shunt placement (12 of 23, 52%) and/or subsequent revisions (11 of 23, 48%) compared with all other infections (9 of 68 [13%] and 13 of 68 [19%], respectively). No differences in reinfection were observed between infecting organism subgroups. Conclusions The organism profile encountered at infection differs when antibiotic-impregnated catheters are used, with a higher proportion of Gram-negative bacilli. This warrants further investigation given increasing adoption of antibiotic-impregnated catheters.

OBJECTIVECSF shunt infection requires both surgical and antibiotic treatment. Surgical treatment includes either total shunt removal with external ventricular drain (EVD) placement followed by new shunt insertion, or distal shunt externalization followed by new shunt insertion once the CSF is sterile. Antibiotic treatment includes the administration of intravenous antibiotics. The Hydrocephalus Clinical Research Network (HCRN) registry provides a unique opportunity to understand reinfection following treatment for CSF shunt infection. This study examines the association of surgical and antibiotic decisions in the treatment of first CSF shunt infection with reinfection.METHODSA prospective cohort study of children undergoing treatment for first CSF infection at 7 HCRN hospitals from April 2008 to December 2012 was performed. The HCRN consensus definition was used to define CSF shunt infection and reinfection. The key surgical predictor variable was surgical approach to treatment for CSF shunt infection, and the key antibiotic treatment predictor variable was intravenous antibiotic selection and duration. Cox proportional hazards models were constructed to address the time-varying nature of the characteristics associated with shunt surgeries.RESULTSOf 233 children in the HCRN registry with an initial CSF shunt infection during the study period, 38 patients (16%) developed reinfection over a median time of 44 days (interquartile range [IQR] 19–437). The majority of initial CSF shunt infections were treated with total shunt removal and EVD placement (175 patients; 75%). The median time between infection surgeries was 15 days (IQR 10–22). For the subset of 172 infections diagnosed by CSF culture, the mean ± SD duration of antibiotic treatment was 18.7 ± 12.8 days. In all Cox proportional hazards models, neither surgical approach to infection treatment nor overall intravenous antibiotic duration was independently associated with reinfection. The only treatment decision independently associated with decreased infection risk was the use of rifampin. While this finding did not achieve statistical significance, in all 5 Cox proportional hazards models both surgical approach (other than total shunt removal at initial CSF shunt infection) and nonventriculoperitoneal shunt location were consistently associated with a higher hazard of reinfection, while the use of ultrasound was consistently associated with a lower hazard of reinfection.CONCLUSIONSNeither surgical approach to treatment nor antibiotic duration was associated with reinfection risk. While these findings did not achieve statistical significance, surgical approach other than total removal at initial CSF shunt infection was consistently associated with a higher hazard of reinfection in this study and suggests the feasibility of controlling and standardizing the surgical approach (shunt removal with EVD placement). Considerably more variation and equipoise exists in the duration and selection of intravenous antibiotic treatment. Further consideration should be given to the use of rifampin in the treatment of CSF shunt infection. High-quality studies of the optimal duration of antibiotic treatment are critical to the creation of evidence-based guidelines for CSF shunt infection treatment.

OBJECTIVEHigh-quality data comparing endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) to shunt and ETV alone in North America are greatly lacking. To address this, the Hydrocephalus Clinical Research Network (HCRN) conducted a prospective study of ETV+CPC in infants. Here, these prospective data are presented and compared to prospectively collected data from a historical cohort of infants treated with shunt or ETV alone.METHODSFrom June 2014 to September 2015, infants (corrected age ≤ 24 months) requiring treatment for hydrocephalus with anatomy suitable for ETV+CPC were entered into a prospective study at 9 HCRN centers. The rate of procedural failure (i.e., the need for repeat hydrocephalus surgery, hydrocephalus-related death, or major postoperative neurological deficit) was determined. These data were compared with a cohort of similar infants who were treated with either a shunt (n = 969) or ETV alone (n = 74) by creating matched pairs on the basis of age and etiology. These data were obtained from the existing prospective HCRN Core Data Project. All patients were observed for at least 6 months.RESULTSA total of 118 infants underwent ETV+CPC (median corrected age 1.3 months; common etiologies including myelomeningocele [30.5%], intraventricular hemorrhage of prematurity [22.9%], and aqueductal stenosis [21.2%]). The 6-month success rate was 36%. The most common complications included seizures (5.1%) and CSF leak (3.4%). Important predictors of treatment success in the survival regression model included older age (p = 0.002), smaller preoperative ventricle size (p = 0.009), and greater degree of CPC (p = 0.02). The matching algorithm resulted in 112 matched pairs for ETV+CPC versus shunt alone and 34 matched pairs for ETV+CPC versus ETV alone. ETV+CPC was found to have significantly higher failure rate than shunt placement (p < 0.001). Although ETV+CPC had a similar failure rate compared with ETV alone (p = 0.73), the matched pairs included mostly infants with aqueductal stenosis and miscellaneous other etiologies but very few patients with intraventricular hemorrhage of prematurity.CONCLUSIONSWithin a large and broad cohort of North American infants, our data show that overall ETV+CPC appears to have a higher failure rate than shunt alone. Although the ETV+CPC results were similar to ETV alone, this comparison was limited by the small sample size and skewed etiological distribution. Within the ETV+CPC group, greater extent of CPC was associated with treatment success, thereby suggesting that there are subgroups who might benefit from the addition of CPC. Further work will focus on identifying these subgroups.

OBJECTIVE: Identify characteristics associated with hospital readmission due to bacterial respiratory tract infections (bRTI) after tracheotomy. STUDY DESIGN: Retrospective study of 8009 children 0–17 years undergoing tracheotomy from 2007–2013 at 48 children’s hospitals in the Pediatric Health Information System database. The primary outcome was first hospital admission after tracheotomy for bRTI (i.e. primary diagnosis of bRTI or a primary diagnosis of bRTI symptom and secondary diagnosis of bRTI). We used Cox-proportional hazard modeling to assess associations between patient demographic and clinical characteristics and bRTI hospital readmission. RESULTS: Median age at tracheotomy admission was 5 months [interquartile range (IQR): 1–50 months]. Thirty-six percent (n=2,899) had at least one bRTI admission. Median time-to-readmission for bRTI was 275 days (IQR: 141–530). Factors independently associated with increased risk for bRTI readmission were younger age [e.g., age 2 complex chronic conditions (vs. zero; aHR 1.96; 95% CI: 1.34–2.86) and discharge to home (vs. post-acute care setting; aHR 1.19; 95% CI: 1.08–1.32). Trauma diagnosis at tracheotomy (aHR 0.83; 95% CI: 0.69–1) and ventilator dependency (aHR 0.88; 95% CI: 0.81–0.97) were associated with decreased risk. CONCLUSIONS: Young, Hispanic children with multiple complex chronic conditions who use Medicaid insurance and are not discharged to post-acute care are at the highest risk for hospital readmission for bRTI post-tracheotomy. Future research should investigate strategies to mitigate this risk for these children.

OBJECTIVEPrevious Hydrocephalus Clinical Research Network (HCRN) retrospective studies have shown a 15% difference in rates of conversion to permanent shunts with the use of ventriculosubgaleal shunts (VSGSs) versus ventricular reservoirs (VRs) as temporization procedures in the treatment of hydrocephalus due to high-grade intraventricular hemorrhage (IVH) of prematurity. Further research in the same study line revealed a strong influence of center-specific decision-making on shunt outcomes. The primary goal of this prospective study was to standardize decision-making across centers to determine true procedural superiority, if any, of VSGS versus VR as a temporization procedure in high-grade IVH of prematurity.METHODSThe HCRN conducted a prospective cohort study across 6 centers with an approximate 1.5- to 3-year accrual period (depending on center) followed by 6 months of follow-up. Infants with premature birth, who weighed less than 1500 g, had Grade 3 or 4 IVH of prematurity, and had more than 72 hours of life expectancy were included in the study. Based on a priori consensus, decisions were standardized regarding the timing of initial surgical treatment, upfront shunt versus temporization procedure (VR or VSGS), and when to convert a VR or VSGS to a permanent shunt. Physical examination assessment and surgical technique were also standardized. The primary outcome was the proportion of infants who underwent conversion to a permanent shunt. The major secondary outcomes of interest included infection and other complication rates.RESULTSOne hundred forty-five premature infants were enrolled and met criteria for analysis. Using the standardized decision rubrics, 28 infants never reached the threshold for treatment, 11 initially received permanent shunts, 4 were initially treated with endoscopic third ventriculostomy (ETV), and 102 underwent a temporization procedure (36 with VSGSs and 66 with VRs). The 2 temporization cohorts were similar in terms of sex, race, IVH grade, head (orbitofrontal) circumference, and ventricular size at temporization. There were statistically significant differences noted between groups in gestational age, birth weight, and bilaterality of clot burden that were controlled for in post hoc analysis. By Kaplan-Meier analysis, the 180-day rates of conversion to permanent shunts were 63.5% for VSGS and 74.0% for VR (p = 0.36, log-rank test). The infection rate for VSGS was 14% (5/36) and for VR was 17% (11/66; p = 0.71). The overall compliance rate with the standardized decision rubrics was noted to be 90% for all surgeons.CONCLUSIONSA standardized protocol was instituted across all centers of the HCRN. Compliance was high. Choice of temporization techniques in premature infants with IVH does not appear to influence rates of conversion to permanent ventricular CSF diversion. Once management decisions and surgical techniques are standardized across HCRN sites, thus minimizing center effect, the observed difference in conversion rates between VSGSs and VRs is mitigated.

Objective Identify risk factors for readmission due to a bacterial tracheostomy-associated respiratory tract infection (bTARTI) within 12 months of discharge after tracheotomy. Design/Methods We performed a retrospective cohort study of 240 children who underwent tracheotomy and were discharged with tracheotsomy in place between January 1, 2005 and June 30, 2013. Children with prolonged total or post-tracheotomy length of stay (LOS), less than 12 months of follow-up, or who died during the index hospitalization were excluded. Readmission for a bTARTI (eg, pneumonia, tracheitis) treated with antibiotics, as ascertained by manual chart review, was the outcome variable. We used multivariate logistic regression to identify the independent association between risk factors and hospital readmission for bTARTI within 12 months. Results At index hospitalizations for tracheotomy, the median admission age was 5 months (interquartile range [IQR] 2-43 months) and median LOS was 73 days (IQR 43-121 days). Most patients were of Hispanic ethnicity (n = 162, 68%) and were publicly insured (n = 213, 89%). Nearly half (n = 112, 47%) were discharged on positive pressure mechanical ventilation. Many (n = 103, 43%) were admitted for bTARTI within 12 months of discharge. Only Hispanic ethnicity (adjusted odds ratio [AOR] 2.0; 95% confidence interval [CI]: 1.1-3.9; P = 0.03) and acquisition of Pseudomonas aeruginosa between tracheotomy and discharge from index hospitalization (AOR 3.2; 95%CI: 1.2-8.3; P = 0.02) were independently associated with increased odds of bTARTI readmission, while discharge on gastrointestinal pro-motility agents was associated with decreased risk (AOR = 0.4; 95%CI: 0.2-0.8; P = 0.01). Conclusions Hispanic ethnicity and post-tracheotomy acquisition of P. aeruginosa during initial hospitalization are associated with bTARTI readmission.

OBJECTIVE Accurate placement of ventricular catheters may result in prolonged shunt survival, but the best target for the hole-bearing segment of the catheter has not been rigorously defined. The goal of the study was to define a target within the ventricle with the lowest risk of shunt failure. METHODS Five catheter placement variables (ventricular catheter tip location, ventricular catheter tip environment, relationship to choroid plexus, catheter tip holes within ventricle, and crosses midline) were defined, assessed for interobserver agreement, and evaluated for their effect on shunt survival in univariate and multivariate analyses. De-identified subjects from the Shunt Design Trial, the Endoscopic Shunt Insertion Trial, and a Hydrocephalus Clinical Research Network study on ultrasound-guided catheter placement were combined (n = 858 subjects, all first-time shunt insertions, all patients < 18 years old). The first postoperative brain imaging study was used to determine ventricular catheter placement for each of the catheter placement variables. RESULTS Ventricular catheter tip location, environment, catheter tip holes within the ventricle, and crosses midline all achieved sufficient interobserver agreement (κ > 0.60). In the univariate survival analysis, however, only ventricular catheter tip location was useful in distinguishing a target within the ventricle with a survival advantage (frontal horn; log-rank, p = 0.0015). None of the other catheter placement variables yielded a significant survival advantage unless they were compared with catheter tips completely not in the ventricle. Cox regression analysis was performed, examining ventricular catheter tip location with age, etiology, surgeon, decade of surgery, and catheter entry site (anterior vs posterior). Only age (p < 0.001) and entry site (p = 0.005) were associated with shunt survival; ventricular catheter tip location was not (p = 0.37). Anterior entry site lowered the risk of shunt failure compared with posterior entry site by approximately one-third (HR 0.65, 95% CI 0.51–0.83). CONCLUSIONS This analysis failed to identify an ideal target within the ventricle for the ventricular catheter tip. Unexpectedly, the choice of an anterior versus posterior catheter entry site was more important in determining shunt survival than the location of the ventricular catheter tip within the ventricle. Entry site may represent a modifiable risk factor for shunt failure, but, due to inherent limitations in study design and previous clinical research on entry site, a randomized controlled trial is necessary before treatment recommendations can be made.

OBJECTIVES:The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions.METHODS:This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children’s discharge from a tertiary children’s hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0–100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions.RESULTS:P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points–greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse.CONCLUSIONS:The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.

OBJECTIVES: To evaluate variation in resource use for children with acute respiratory tract illness (ARTI) by vaccination status. METHODS: We conducted a retrospective cohort study of children 0 to 16 years of age at 5 children’s hospitals with 1 of 4 ARTI diagnoses (pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status (yes or no). Outcomes were receipt of each of the following tests or treatments (yes or no): complete blood cell count, blood cultures, C-reactive protein (CRP) level testing, viral testing, influenza testing, pertussis testing, chest radiographs, neck radiographs, antibiotics, and corticosteroids. We generated multivariable logistic regression models to examine the associations between our predictor and outcomes. RESULTS: Of the 2302 participants included in analysis, 568 (25%) were diagnosed with pneumonia, 343 (15%) were diagnosed with croup, 653 (28%) were diagnosed with asthma, and 738 (32%) were diagnosed with bronchiolitis. Most (92%) vaccination statuses were documented as UTD. Across conditions, children whose vaccination status was documented as not UTD had higher adjusted odds of receiving a complete blood cell count, blood culture, CRP level testing, and influenza testing (P < .001). Children with pneumonia whose vaccination status was documented as not UTD had higher adjusted odds of receiving CRP level testing and influenza testing (P < .001). Children with croup whose vaccination status was documented as not UTD had higher adjusted odds of receiving blood cultures (P < .001). CONCLUSIONS: Children with ARTI whose vaccination status was documented as not UTD had higher odds of undergoing laboratory testing compared with children whose vaccination status was documented as UTD.

BACKGROUND AND OBJECTIVES: The Pediatric Respiratory Illness Measurement System (PRIMES) generates condition-specific composite quality scores for asthma, bronchiolitis, croup, and pneumonia in hospital-based settings. We sought to determine if higher PRIMES composite scores are associated with improved health-related quality of life, decreased length of stay (LOS), and decreased reuse. METHODS: We conducted a prospective cohort study of 2334 children in 5 children’s hospitals between July 2014 and June 2016. Surveys administered on admission and 2 to 6 weeks postdischarge assessed the Pediatric Quality of Life Inventory (PedsQL). Using medical records data, 3 PRIMES scores were calculated (0–100 scale; higher scores = improved adherence) for each condition: an overall composite (including all quality indicators for the condition), an overuse composite (including only indicators for care that should not be provided [eg, chest radiographs for bronchiolitis]), and an underuse composite (including only indicators for care that should be provided [eg, dexamethasone for croup]). Multivariable models assessed relationships between PRIMES composite scores and (1) PedsQL improvement, (2) LOS, and (3) 30-day reuse. RESULTS: For every 10-point increase in PRIMES overuse composite scores, LOS decreased by 8.8 hours (95% confidence interval [CI] −11.6 to −6.1) for bronchiolitis, 3.1 hours (95% CI −5.5 to −1.0) for asthma, and 2.0 hours (95% CI −3.9 to −0.1) for croup. Bronchiolitis overall composite scores were also associated with shorter LOS. PRIMES composites were not associated with PedsQL improvement or reuse. CONCLUSIONS: Better performance on some PRIMES condition-specific composite measures is associated with decreased LOS, with scores on overuse quality indicators being a primary driver of this relationship.

To ensure that new health information technology supports its intended users, researchers and developers need to follow human-centered methods during all stages of the software development lifecycle, including early stage evaluations. These evaluations need to include realistic testing scenarios to ensure that they provide valuable and accurate feedback to system developers. However, obtaining realistic patient data to support these evaluations has many challenges, including the risk of re-identifying anonymized patients as well as the costs associated with connecting test systems with production ready clinical databases. Here we present a novel five-step process to create highly structured and realistic synthetic patient data to support the evaluation and comparison of early to middle stage health information technology prototypes. We applied this method to evaluate and compare three novel health information technology prototypes designed to support clinicians during the identification of high-priority patients when answering the question: "What patient should I see first?" Our novel approach fills an important gap in the evaluation of health information technology and assists designers in creating high-quality software that best supports its end users.

Background Few measures exist to assess pediatric transition quality between care settings. The study objective was to develop and pilot test caregiver-reported quality measures for pediatric hospital and emergency department (ED) to home transitions. Methods On the basis of an evidence review, we developed draft caregiver-reported quality measures for transitions between sites of care. Using the RAND-UCLA Modified Delphi method, a multistakeholder panel endorsed measures for further development. Measures were operationalized into 2 surveys, which were administered to caregivers of patients (n = 2839) discharged from Seattle Children's Hospital between July 1 and September 1, 2014. Caregivers were randomized to mail or telephone survey mode. Measure scores were computed as a percentage of eligible caregivers who endorsed receiving the indicated care. Differences in scores were examined according to survey mode and caregiver characteristics. Results The Delphi panel endorsed 6 of 8 hospital to home transition measures and 2 of 3 ED to home transitions measures. Scores differed significantly according to mode for 1 measure. Caregivers with lower levels of educational attainment and/or Spanish-speaking caregivers reported significantly higher scores on 3 of the measures. The largest difference was reported for the measure that assessed whether caregivers received assistance with scheduling follow-up appointments; 92% score for caregivers with lower educational attainment versus 79% for caregivers with higher educational attainment ( P Conclusions We developed 8 new, evidence-based quality measures to assess transition quality from the perspective of caregivers. Pilot testing of these measures in a single institution yielded valuable insights for future testing and implementation of these measures.

OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori–defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1–2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0–2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2–2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor—an existing cardiac comorbidity—was also associated with shunt failure.

Congenital heart disease (CHD) is common in newborns with myelomeningocele. Echocardiography before neonatal back closure has been recommended. Its utility in the era of prenatal diagnosis is unclear. We reviewed all newborns with myelomeningocele evaluated by preoperative echocardiography at our institution over 11 years. Seventy-six successive newborns were identified. Ninety-one percent were prenatally diagnosed with myelomeningocele. In all, 1% had critical, 12% critical or non-critical and 22% critical, non-critical or possible CHD. The single case of critical CHD was both prenatally diagnosed and clinically identifiable. The prevalence of CHD in newborns with myelomeningocele is increased compared with the general population; however, critical disease is uncommon. We propose preoperative echocardiography is unnecessary when the myelomeningocele is prenatally diagnosed, antenatal cardiac screening is complete and normal, and the newborn is clinically well.

Objective To modify the Pediatric Medical Complexity Algorithm (PMCA) to include both International Classification of Diseases, Ninth and Tenth Revisions, Clinical Modification (ICD-9/10-CM) codes for classifying children with chronic disease (CD) by level of medical complexity and to assess the sensitivity and specificity of the new PMCA version 3.0 for correctly identifying level of medical complexity. Methods To create version 3.0, PMCA version 2.0 was modified to include ICD-10-CM codes. We applied PMCA version 3.0 to Seattle Children's Hospital data for children with ≥1 emergency department (ED), day surgery, and/or inpatient encounter from January 1, 2016, to June 30, 2017. Starting with the encounter date, up to 3 years of retrospective discharge data were used to classify children as having complex chronic disease (C-CD), noncomplex chronic disease (NC-CD), and no CD. We then selected a random sample of 300 children (100 per CD group). Blinded medical record review was conducted to ascertain the levels of medical complexity for these 300 children. The sensitivity and specificity of PMCA version 3.0 was assessed. Results PMCA version 3.0 identified children with C-CD with 86% sensitivity and 86% specificity, children with NC-CD with 65% sensitivity and 84% specificity, and children without CD with 77% sensitivity and 93% specificity. Conclusions PMCA version 3.0 is an updated publicly available algorithm that identifies children with C-CD, who have accessed tertiary hospital emergency department, day surgery, or inpatient care, with very good sensitivity and specificity when applied to hospital discharge data and with performance to earlier versions of PMCA.

OBJECTIVES:To assess whether children with medical complexity (CMC) exposed to a hospital-based comprehensive case management service (CCMS) experience improved health care quality, improved functional status, reduced hospital-based utilization, and/or reduced overall health care costs.METHODS:Eligible CMC at Seattle Children’s Hospital were enrolled in a cluster randomized controlled trial between December 1, 2010, and September 29, 2014. Participating primary care providers (PCPs) were randomly assigned, and CMC either had access to an outpatient hospital-based CCMS or usual care directed by their PCP. The CCMS included visits to a multidisciplinary clinic ≥ every 6 months for 1.5 years, an individualized shared care plan, and access to CCMS providers. Differences between control and intervention groups in change from baseline to 12 months and baseline to 18 months (difference of differences) were tested.RESULTS:Two hundred PCPs caring for 331 CMC were randomly assigned. Intervention group (n = 181) parents reported more improvement in the Consumer Assessment of Healthcare Providers and Systems version 4.0 Child Health Plan Survey global health care quality ratings than control group parents (6.7 [95% confidence interval (CI): 3.5–9.8] vs 1.3 [95% CI: 1.9–4.6] at 12 months). We did not detect significant differences in child functional status and most hospital-based utilization between groups. The difference in change of overall health care costs was higher in the intervention group (+$8233 [95% CI: $1701–$16 937]) at 18 months). CCMS clinic costs averaged $3847 per child-year.CONCLUSIONS:Access to a CCMS generally improved health care quality, but was not associated with changes in child functional status or hospital-based utilization, and increased overall health care costs among CMC.

BACKGROUND AND OBJECTIVES: The Pediatric Medical Complexity Algorithm (PMCA) was developed to stratify children by level of medical complexity. We sought to refine PMCA and evaluate its performance based on the duration of eligibility and completeness of Medicaid data. METHODS: PMCA version 1.0 was applied to a cohort of 299 children insured by Washington State Medicaid with ≥1 Seattle Children’s Hospital outpatient, emergency department, and/or inpatient encounter in 2012. Blinded assessment of the validation cohort’s PMCA category was performed by using medical records. In-depth review of discrepant cases was performed and informed the development of PMCA version 2.0. The sensitivity and specificity of PMCA version 2.0 were assessed. RESULTS: Using Medicaid data, the sensitivity of PMCA version 2.0 was 74% for complex chronic disease (C-CD), 60% for noncomplex chronic disease (NC-CD), and 87% for those without chronic disease (CD). Specificity was 84% to 91% in Medicaid data for all 3 groups. Medicaid data were most complete for children that had primarily fee-for-service claims and were less complete for those with some managed care encounter data. PMCA version 2.0 performed optimally when children had a longer duration of coverage (25 to 36 months) with fee-for-service reimbursement, identifying children with C-CD with 85% sensitivity and 75% specificity, children with NC-CD with 55% sensitivity and 88% specificity, and children without CD with 100% sensitivity and 97% specificity. CONCLUSIONS: PMCA version 2.0 identifies children with C-CD with good sensitivity and very good specificity when applied to Medicaid data. Data quality is a critical consideration when using PMCA.

OBJECTIVES: The goal of this study was to develop an algorithm based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes for classifying children with chronic disease (CD) according to level of medical complexity and to assess the algorithm’s sensitivity and specificity. METHODS: A retrospective observational study was conducted among 700 children insured by Washington State Medicaid with ≥1 Seattle Children’s Hospital emergency department and/or inpatient encounter in 2010. The gold standard population included 350 children with complex chronic disease (C-CD), 100 with noncomplex chronic disease (NC-CD), and 250 without CD. An existing ICD-9-CM–based algorithm called the Chronic Disability Payment System was modified to develop a new algorithm called the Pediatric Medical Complexity Algorithm (PMCA). The sensitivity and specificity of PMCA were assessed. RESULTS: Using hospital discharge data, PMCA’s sensitivity for correctly classifying children was 84% for C-CD, 41% for NC-CD, and 96% for those without CD. Using Medicaid claims data, PMCA’s sensitivity was 89% for C-CD, 45% for NC-CD, and 80% for those without CD. Specificity was 90% to 92% in hospital discharge data and 85% to 91% in Medicaid claims data for all 3 groups. CONCLUSIONS: PMCA identified children with C-CD (who have accessed tertiary hospital care) with good sensitivity and good to excellent specificity when applied to hospital discharge or Medicaid claims data. PMCA may be useful for targeting resources such as care coordination to children with C-CD.

Pediatric hospitalists care for many hospitalized children in community and academic settings, and they must partner with administrators, other inpatient care providers, and researchers to assure the reliable delivery of high-quality, safe, evidence-based, and cost-effective care within the complex inpatient setting. Paralleling the growth of the field of pediatric hospital medicine is the realization that innovations are needed to address some of the most common clinical questions. Some of the unique challenges facing pediatric hospitalists include the lack of evidence for treating common conditions, children with chronic complex conditions, compressed time frame for admissions, and the variety of settings in which hospitalists practice. Most pediatric hospitalists are engaged in some kind of quality improvement (QI) work as hospitals provide many opportunities for QI activity and innovation. There are multiple national efforts in the pediatric hospital medicine community to improve quality, including the Children's Hospital Association (CHA) collaboratives and the Value in Pediatrics Network (VIP). Pediatric hospitalists are also challenged by the differences between QI and QI research; understanding that while improving local care is important, to provide consistent quality care to children we must study single-center and multicenter QI efforts by designing, developing, and evaluating interventions in a rigorous manner, and examine how systems variations impact implementation. The Pediatric Research in Inpatient Setting (PRIS) network is a leader in QI research and has several ongoing projects. The Prioritization project and Pediatric Health Information System Plus (PHIS+) have used administrative data to study variations in care, and the IIPE-PRIS Accelerating Safe Sign-outs (I-PASS) study highlights the potential for innovative QI research methods to improve care and clinical training. We address the importance, current state, accomplishments, and challenges of QI and QI research in pediatric hospital medicine; define the role of the PRIS Network in QI research; describe an exemplary QI research project, the I-PASS Study; address challenges for funding, training and mentorship, and publication; and identify future directions for QI research in pediatric hospital medicine.

Objective To describe typical care experiences and key barriers and facilitators to caring for children with medical complexity (CMC) from the perspective of community primary care providers (PCPs). Study design PCPs participating in a randomized controlled trial of a care-coordination intervention for CMC were sent a 1-time cross-sectional survey that asked PCPs to (1) describe their experiences with caring for CMC; (2) identify key barriers affecting their ability to care for CMC; and (3) prioritize facilitators enhancing their ability to provide care coordination for CMC. PCP and practice demographics also were collected. Results One hundred thirteen of 155 PCPs sent the survey responded fully (completion rate = 73%). PCPs endorsed that medical characteristics such as polypharmacy (88%), multiorgan system involvement (84%), and rare/unfamiliar diagnoses (83%) negatively affected care. Caregivers with high needs (88%), limited time with patients and caregivers (81%), and having a large number of specialists involved in care (79%) were also frequently cited. Most commonly endorsed strategies to improve care coordination included more time with patients/caregivers (84%), summative action plans (83%), and facilitated communication (eg, e-mail, phone meetings) with specialists (83%). Conclusions Community PCPs prioritized more time with patients and their families, better communication with specialists, and summative action plans to improve care coordination for this vulnerable population. Although this study evaluated perceptions rather than actual performance, it provides insights to improve understanding of which barriers and facilitators ideally might be targeted first for care delivery redesign.

BACKGROUND: Transitions between sites of care are inherent to all hospitalizations, yet we lack pediatric-specific transitions-of-care quality measures. We describe the development and validation of new transitions-of-care quality measures obtained from medical record data. METHODS: After an evidence review, a multistakeholder panel prioritized quality measures by using the RAND/University of California, Los Angeles modified Delphi method. Three measures were endorsed, operationalized, and field-tested at 3 children’s hospitals and 2 community hospitals: quality of hospital-to-home transition record content, timeliness of discharge communication between inpatient and outpatient providers, and ICU-to-floor transition note quality. Summary scores were calculated on a scale from 0 to 100; higher scores indicated better quality. We examined between-hospital variation in scores, associations of hospital-to-home transition quality scores with readmission and emergency department return visit rates, and associations of ICU-to-floor transition quality scores with ICU readmission and length of stay. RESULTS: A total of 927 charts from 5 hospitals were reviewed. Mean quality scores were 65.5 (SD 18.1) for the hospital-to-home transition record measure, 33.3 (SD 47.1) for the discharge communication measure, and 64.9 (SD 47.1) for the ICU-to-floor transition measure. The mean adjusted hospital-to-home transition summary score was 61.2 (SD 17.1), with significant variation in scores between hospitals (P < .001). Hospital-to-home transition quality scores were not associated with readmissions or emergency department return visits. ICU-to-floor transition note quality scores were not associated with ICU readmissions or hospital length of stay. CONCLUSIONS: These quality measures were feasible to implement in diverse settings and varied across hospitals. The development of these measures is an important step toward standardized evaluation of the quality of pediatric transitional care.

A small group of children have second and even more cerebrospinal fluid (CSF) shunt infections (SIs). We sought to describe the treatment approaches used for, and the microbiology of, repeated SIs.The study population included 31 children with second shunt infection (SI-2) among those undergoing initial CSF shunt placement and treatment for initial infection at Primary Children's Medical Center. CSF SI was defined as follows: (1) presence of bacteria in Gram stain and/or culture of CSF, wound, and/or pseudocyst; (2) visible hardware; (3) abdominal pseudocyst; or (4) presence of bacteria in a blood culture in children with a ventriculoatrial shunt. Infection rates were generated using per-patient denominators, and the concordance of organisms across infections was summarized.Of the 31 children with SI-2, most were less than 6 months of age at initial shunt placement (81%), male (77%), and with ventriculoperitoneal shunts (71%). Of total, 18 developed SI-3 and 8 developed SI-4. Infection rates were 60% (95% confidence interval [CI]: 42%-75%, n = 18/30) for SI-3 and 47% (95% CI: 26%-69%, n = 8/17) for SI-4. The median time to SI-3 was 477 days (range, 5-828) and to SI-4 it was 2137 days (range, 9-2137). Gram-positive organisms predominated (93% of SI-2, 94% of SI-3). The majority of SI-2 demonstrated Gram-stain concordance with both the initial (first) SI (58%, 95% CI: 41%-74%) and with the following (third) SI (78%, 95% CI: 55%-91%).Children with SI-2 experience high subsequent reinfection rates with a long time to reinfection.

Latino children have lower visit rates to emergency departments and primary care physicians than white children in the USA. Using a nationally representative household survey, this study asked whether parental report of injury was also lower for Latino children, after adjusting for demographic, socioeconomic, health status and health care access factors. Data were obtained on injuries for which medical advice or treatment was received from the National Health Interview Survey (NHIS) from 1997 to 2003. Using the multistage probability design of NHIS, annual rates and adjusted odds of childhood injury report by race and ethnicity were calculated. Respondents reported lower rates of injury for Latino children (6.0 (95% CI 5.3-6.8)/100 person-years) than white children (13.4 (12.7-14.2)/100 person-years). Lower injury rates were mainly due to lower rates of sports injuries and accidental falls. Latino children had lower odds of reported injury than white children, even after adjusting for multiple factors (odds ratio 0.7; 95% CI 0.6-0.8). Lower odds of injury report among Latino children are independent of direct measures of demographic, socioeconomic, health status and health care access factors and indirect measures of acculturation including respondent language and country of origin. Potential explanations include lower exposure to risk, greater child supervision, reporting bias, differences in cultural attitudes toward seeking of health care and reduced health care access that cannot be explored in NHIS due to the form of the current questions. Further research is needed to investigate cultural differences in risk exposure, child supervision and seeking of injury care.

Object The aims of this study were to measure inpatient health care for pediatric hydrocephalus in the US; describe patient, hospital, and hospitalization characteristics for pediatric hydrocephalus inpatient care; and determine characteristics associated with death. Methods A cross-sectional study was performed using the 1997, 2000, and 2003 Healthcare Cost and Utilization Project Kids' Inpatient Databases (KID), nationally representative weighted data sets of hospital discharges for pediatric patients. A hydrocephalus-related hospitalization was classified as either cerebrospinal fluid (CSF) shunt–related (including initial placements, infections, malfunctions, or other) or non–CSF shunt–related. Patients > 18 years of age were excluded. The KID provided weighted estimates of 6.657, 6.597, and 6.732 million total discharges in the 3 study years. Results Each year there were 38,200–39,900 admissions, 391,000–433,000 hospital days, and total hospital charges of $1.4–2.0 billion for pediatric hydrocephalus. Hydrocephalus accounted for 0.6% of all pediatric hospital admissions in the US in 2003, but for 1.8% of all pediatric hospital days and 3.1% of all pediatric hospital charges. Over the study years, children admitted with hydrocephalus were older, had an increase in comorbidities, and were admitted more frequently to teaching hospitals. Compared with children who survived, those who died were more likely to be < 3 months of age and have a birth-related admission, have no insurance, have comorbidities, be transferred, and have a non–CSF shunt–related admission. Conclusions Children with hydrocephalus have a chronic illness and use a disproportionate share of hospital days and healthcare dollars in the US. Since 1997 they have increased in age and in number of comorbid conditions. For important changes in morbidity and mortality rates to be made, focused research efforts and funding are necessary.

To describe clinician delivery of injury prevention anticipatory guidance and injury visits in a birth cohort, and to describe the association of injury prevention anticipatory guidance with subsequent injury visits.We performed a prospective cohort study of 2610 infants born from July 1, 1998 to June 30, 1999, at an urban safety-net hospital and seen subsequently for well child care (WCC, visits = 10558) and/or injury by 16 months of age. Injury guidance was defined as the proportion of recommended injury prevention anticipatory guidance items delivered to those expected, given the WCC visits the child attended. The outcome was a first injury visit to a clinic, emergency department, or hospital.The injury prevention items most discussed were car seats (84%-95% of all WCC visits) and rolling over at the 2-month WCC visit (80%). Other items were addressed at 36%-69% of visits. A total of 1931 (74%) of children receivedor = 50% expected injury guidance. A total of 277 children (11%) had an injury visit, primarily for minor injuries. In unadjusted analysis, children receiving25% expected injury guidance were more likely to have a subsequent injury visit (unadjusted odds ratio 6.2; 95% confidence interval [95% CI] 3.2-9.7). In adjusted analysis, children who received25% and 25%-49% expected injury guidance were more likely to have a subsequent injury visits (adjusted odds ratio [AOR] 6.6; 95% CI 3.8-11.2; and AOR 2.9, 95% CI 2.0-4.3, respectively).Disadvantaged children whose families received less injury guidance than other children in their cohort were more likely to have a subsequent injury visit. Further studies are needed to determine whether increased injury prevention counseling reduces injury visits.

OBJECTIVES:: (1) To characterize the demographics and external causes of pediatric sports injury-related visits (SIRVs) to emergency departments (EDs). (2) To analyze the effect of race/ethnicity and insurance on SIRVs to EDs. METHODS:: A stratified random-sample cross-sectional survey of EDs in the National Hospital Ambulatory Medical Care Survey was conducted from 1997-2001; for patients younger than 19 years, we used all visits [n = 33,654; injury-related visits (IRVs) = 13,496, SIRVs = 2990]. We examined both the external cause codes and the actual verbatim text of all IRVs. National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the National Hospital Ambulatory Medical Care Survey databases and SUDAAN 9.1 software (SAS Institute, Inc., Cary, NC). RESULTS:: Sports injuries resulted in 2.5 million visits annually, or 23% of ED IRVs. Male sex, older age (6-18 years), and white race/ethnicity are associated with higher rates of SIRVs. Cycling, basketball, playground injuries, and football resulted in the largest numbers of ED SIRVs. Leading diagnoses for SIRVs included fractures and dislocations, sprains and strains, open wounds, and contusions. Hispanic race/ethnicity was associated with lower rates of SIRVs across all insurance types. After controlling for demographic factors and insurance, Hispanic children were less likely to have an SIRV than white children (odds ratio, 0.7; 95% confidence interval, 0.6-0.9). CONCLUSIONS:: Sports and recreation are the leading causes of pediatric ED IRVs. Hispanic children, regardless of insurance status, had lower rates of SIRVs than white children, which helps explain the lower rate of nonfatal IRVs to EDs among Hispanic youth. Language: en

Object Shunt survival may improve when ventricular catheters are placed into the frontal horn or trigone of the lateral ventricle. However, techniques for accurate catheter placement have not been developed. The authors recently reported a prospective study designed to test the accuracy of catheter placement with the assistance of intraoperative ultrasound, but the results were poor (accurate placement in 59%). A major reason for the poor accurate placement rate was catheter movement that occurred between the time of the intraoperative ultrasound image and the first postoperative scan (33% of cases). The control group of non–ultrasound using surgeons also had a low rate of accurate placement (accurate placement in 49%). The authors conducted an exploratory post hoc analysis of patients in their ultrasound study to identify factors associated with either catheter movement or poor catheter placement so that improved surgical techniques for catheter insertion could be developed. Methods The authors investigated the following risk factors for catheter movement and poor catheter placement: age, ventricular size, cortical mantle thickness, surgeon experience, surgeon experience with ultrasound prior to trial, shunt entry site, shunt hardware at entry site, ventricular catheter length, and use of an ultrasound probe guide for catheter insertion. Univariate analysis followed by multivariate logistic regression models were used to determine which factors were independent risk factors for either catheter movement or inaccurate catheter location. Results In the univariate analyses, only age < 6 months was associated with catheter movement (p = 0.021); cortical mantle thickness < 1 cm was near-significant (p = 0.066). In a multivariate model, age remained significant after adjusting for cortical mantle thickness (OR 8.35, exact 95% CI 1.20–infinity). Univariate analyses of factors associated with inaccurate catheter placement showed that age < 6 months (p = 0.001) and a posterior shunt entry site (p = 0.021) were both associated with poor catheter placement. In a multivariate model, both age < 6 months and a posterior shunt entry site were independent risk factors for poor catheter placement (OR 4.54, 95% CI 1.80–11.42, and OR 2.59, 95% CI 1.14–5.89, respectively). Conclusions Catheter movement and inaccurate catheter placement are both more likely to occur in young patients (< 6 months). Inaccurate catheter placement is also more likely to occur in cases involving a posterior shunt entry site than those involving an anterior shunt entry site. Future clinical studies aimed at improving shunt placement techniques must consider the effects of young age and choice of entry site on catheter location.

Object The Hydrocephalus Clinical Research Network (HCRN), which comprises 7 pediatric neurosurgical centers in North America, provides a unique multicenter assessment of the current outcomes of CSF shunting in nonselected patients. The authors present the initial results for this cohort and compare them with results from prospective multicenter trials performed in the 1990s. Methods Analysis was restricted to patients with newly diagnosed hydrocephalus undergoing shunting for the first time. Detailed perioperative data from 2008 through 2012 for all HCRN centers were prospectively collected and centrally stored by trained research coordinators. Historical control data were obtained from the Shunt Design Trial (1993–1995) and the Endoscopic Shunt Insertion Trial (1996–1999). The primary outcome was time to first shunt failure, which was determined by using Cox regression survival analysis. Results Mean age of the 1184 patients in the HCRN cohort was older than mean age of the 720 patients in the historical cohort (2.51 years vs 1.60 years, p < 0.0001). The distribution of etiologies differed (p < 0.0001, chi-square test); more tumors and fewer myelomeningoceles caused the hydrocephalus in the HCRN cohort patients. The hazard ratio for first shunt failure significantly favored the HCRN cohort, even after the model was adjusted for the prognostic effects of age and etiology (adjusted HR 0.82, 95% CI 0.69–0.96). Conclusions Current outcomes of shunting in general pediatric neurosurgery practice have improved over those from the 1990s, although the reasons remain unclear.

OBJECTIVES:To characterize the use of and disposition from a tertiary pediatric emergency department (PED) by children with chronic conditions with varying degrees of medical complexity.METHODS:We conducted a retrospective cohort study using a dataset of all registered PED patient visits at Seattle Children’s Hospital from January 1, 2008, through December 31, 2009. Children’s medical complexity was classified by using a validated algorithm (Clinical Risk Group software) into nonchronic and chronic conditions: episodic chronic, lifelong chronic, progressive chronic, and malignancy. Outcomes included PED length of stay (LOS) and disposition. Logistic regression generated age-adjusted odds ratios (AOR) of admission with 95% confidence intervals (CIs).RESULTS:PED visits totaled 77 748; 20% (15 433) of which were for children with chronic conditions. Compared with visits for children without chronic conditions, those for children with chronic conditions had increased PED LOS (on average, 79 minutes longer; 95% CI 77–81; P < .0001) and hospital (51% vs 10%) and PICU (3.2% vs 0.1%) admission rates (AOR 10.3, 95% CI 9.9–10.7 to hospital and AOR 25.0, 95% CI 17.0–36.0 to PICU). Admission rates and PED LOS increased with increasing medical complexity.CONCLUSIONS:Children with chronic conditions comprise a significant portion of annual PED visits in a tertiary pediatric center; medical complexity is associated with increased PED LOS and hospital or PICU admission. Clinical Risk Group may have utility in identifying high utilizers of PED resources and help support the development of interventions to facilitate optimal PED management, such as pre-arrival identification and individual emergency care plans.

Objectives To describe the variation in approaches to surgical and antibiotic treatment for first cerebrospinal fluid (CSF) shunt infection and adherence to Infectious Diseases Society of America (IDSA) guidelines. Study design We conducted a prospective cohort study of children undergoing treatment for first CSF infection at 7 Hydrocephalus Clinical Research Network hospitals from April 2008 through December 2012. Univariate analyses were performed to describe the study population. Results A total of 151 children underwent treatment for first CSF shunt-related infection. Most children had undergone initial CSF shunt placement before the age of 6 months (n = 98, 65%). Median time to infection after shunt surgery was 28 days (IQR 15-52 days). Surgical management was most often shunt removal with interim external ventricular drain placement, followed by new shunt insertion (n = 122, 81%). Median time from first negative CSF culture to final surgical procedure was 14 days (IQR 10-21 days). Median duration of intravenous (IV) antibiotic use duration was 19 days (IQR 12-28 days). For 84 infections addressed by IDSA guidelines, 7 (8%) met guidelines and 61 (73%) had longer duration of IV antibiotic use than recommended. Conclusions Surgical treatment for infection frequently adheres to IDSA guidelines of shunt removal with external ventricular drain placement followed by new shunt insertion. However, duration of IV antibiotic use in CSF shunt infection treatment was consistently longer than recommended by the 2004 IDSA guidelines.

To examine the proportionate use of critical care resources among children of differing medical complexity admitted to pediatric intensive care units (ICUs) in tertiary-care children's hospitals.This is a retrospective, cross-sectional study of all children (19 years of age) admitted to a pediatric ICU between January 1, 2012, and December 31, 2013, in the Pediatric Health Information Systems database. Using the Pediatric Medical Complexity Algorithm, we assigned patients to 1 of 3 categories: no chronic disease, noncomplex chronic disease (NC-CD), or complex chronic disease (C-CD). Baseline demographics, hospital costs, and critical care resource use were stratified by these groups and summarized.Of 136 133 children with pediatric ICU admissions, 53.0% were categorized as having C-CD. At the individual-encounter level, ICU resource use was greatest among patients with C-CD compared with children with NC-CD and no chronic disease. At the hospital level, patients with C-CD accounted for more than 75% of all examined ICU resources, including ventilation days, ICU costs, extracorporeal membrane oxygenation runs, and arterial and central venous catheters. Children with a progressive condition accounted for one-half of all ICU resources. In contrast, patients with no chronic disease and NC-CD accounted for less than one-quarter of all ICU therapies.Children with medical complexity disproportionately use the majority of ICU resources in children's hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.

BACKGROUND The object of this study was to determine whether cerebrospinal fluid (CSF) shunt revision(s) are associated with increased risk of CSF shunt infection, after adjusting for baseline factors that contribute to infection risk. METHODS This was a retrospective cohort study of 579 children aged 0-18 years who underwent initial CSF shunt placement between January 01, 1997 and October 12, 2006 at a tertiary care children's hospital. The outcome of interest was CSF shunt infection. Data for all subsequent CSF shunt revisions leading up to and including the initial CSF shunt infection, when applicable, were obtained. The likelihood of infection was determined using a Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HR) with 95% confidence intervals (CI). RESULTS There were 123 children who developed infection. Baseline factors independently associated with hazard of infection included age 0 to

Detailed costs to individuals with hydrocephalus and their families as well as to third-party payers have not been previously described. The purpose of this study was to determine the primary caregiver out-of-pocket expenses and the third-party payer reimbursement rate associated with a shunt failure episode.A retrospective study of children born between 2000 and 2005 who underwent initial ventriculoperitoneal (VP) shunt placement and who subsequently experienced a shunt failure requiring surgical intervention within 2 years of their initial shunt placement was conducted. Institutional reimbursement and demographic data from Children's Hospital of Alabama (CHA) were augmented with a caregiver survey of any out-of pocket expenses encountered during the shunt failure episode. Institutional reimbursements and caregiver out-of-pocket expenses were then combined to provide the cost for a shunt failure episode at CHA.For shunt failures, the median reimbursement total was $5008 (interquartile range [IQR] $2068-$17,984), the median caregiver out-of-pocket expenses was $419 (IQR $251-$1112), and the median total cost was $5411 (IQR $2428-$18,582). Private insurance reimbursed at a median rate of $5074 (IQR $2170-$14,852) compared with public insurance, which reimbursed at a median rate of $4800 (IQR $1876-$19,395). Caregivers with private insurance reported a median $963 (IQR $322-$1741) for out-of-pocket expenses, whereas caregivers with public insurance reported a median $391 (IQR $241-$554) for out-of-pocket expenses (p = 0.017).This study confirmed that private insurance reimbursed at a higher rate, and that although patients had a shorter length of stay as compared with those with public insurance, their out-of-pocket expenses associated with a shunt failure episode were greater. However, it could not be determined if the significant difference in out-of-pocket expenses between those with private and those with public insurance was due directly to the cost of shunt failure. This model does not take into consideration community resources and services available to those with public insurance. These resources and services could offset the out-of-pocket burden, and therefore should be considered in future cost models.

Quality improvement techniques are being implemented in many areas of medicine. In an effort to reduce the ventriculoperitoneal shunt infection rate, a standardized protocol was developed and implemented at 4 centers of the Hydrocephalus Clinical Research Network (HCRN).The protocol was developed sequentially by HCRN members using the current literature and prior institutional experience until consensus was obtained. The protocol was prospectively applied at each HCRN center to all children undergoing a shunt insertion or revision procedure. Infections were defined on the basis of CSF, wound, or pseudocyst cultures; wound breakdown; abdominal pseudocyst; or positive blood cultures in the presence of a ventriculoatrial shunt. Procedures and infections were measured before and after protocol implementation.Twenty-one surgeons at 4 centers performed 1571 procedures between June 1, 2007, and February 28, 2009. The minimum follow-up was 6 months. The Network infection rate decreased from 8.8% prior to the protocol to 5.7% while using the protocol (p = 0.0028, absolute risk reduction 3.15%, relative risk reduction 36%). Three of 4 centers lowered their infection rate. Shunt surgery after external ventricular drainage (with or without prior infection) had the highest infection rate. Overall protocol compliance was 74.5% and improved over the course of the observation period. Based on logistic regression analysis, the use of BioGlide catheters (odds ratio [OR] 1.91, 95% CI 1.19-3.05; p = 0.007) and the use of antiseptic cream by any members of the surgical team (instead of a formal surgical scrub by all members of the surgical team; OR 4.53, 95% CI 1.43-14.41; p = 0.01) were associated with an increased risk of infection.The standardized protocol for shunt surgery significantly reduced shunt infection across the HCRN. Overall protocol compliance was good. The protocol has established a common baseline within the Network, which will facilitate assessment of new treatments. Identification of factors associated with infection will allow further protocol refinement in the future.

Significant variation exists in the surgical and medical management of CSF shunt infection. The objectives of this study were to determine CSF shunt reinfection rates following initial CSF shunt infection in a large patient cohort and to determine management, patient, hospital, and surgeon factors associated with CSF shunt reinfection.This retrospective cohort study included children who were in the Pediatric Health Information System (PHIS) database, who ranged in age from 0 to 18 years, and who underwent uncomplicated initial CSF shunt placement in addition to treatment for initial CSF shunt infection between January 1, 2001, and December 31, 2008. The outcome was CSF shunt reinfection within 6 months. The main predictor variable of interest was surgical approach to treatment of first infection, which was determined for 483 patients. Covariates included patient, hospital, surgeon, and other management factors.The PHIS database includes 675 children with initial CSF shunt infection. Surgical approach to treatment of the initial CSF shunt infection was determined for 483 children (71.6%). The surgical approach was primarily shunt removal/new shunt placement (in 286 children [59.2%]), but a substantial number underwent externalization (59 children [12.2%]), of whom a subset went on to have the externalized shunt removed and a new shunt placed (17 children [3.5% overall]). Other approaches included nonsurgical management (64 children [13.3%]) and complete shunt removal without shunt replacement (74 children [15.3%]). The 6-month reinfection rate was 14.8% (100 of 675 patients). The median time from infection to reinfection was 21 days (interquartile range [IQR] 5-58 days). Children with reinfection had less time between shunt placement and initial infection (median 50 vs 79 days, p = 0.06). No differences between those with and without reinfection were seen in patient factors (patient age at either shunt placement or initial infection, sex, race/ethnicity, payer, indication for shunt, number of comorbidities, distal shunt location, and number of shunt revisions at first infection); hospital volume; surgeon volume; or other management factors (for example, duration of intravenous antibiotic use). Nonsurgical management was associated with reinfection, and complete shunt removal was negatively associated with reinfection. However, reinfection rates did not differ between the 2 most common surgical approaches: shunt removal/new shunt placement (44 [15.4%] of 286; 95% CI 11.4%-20.1%) and externalization (total 12 [20.3%] of 59; 95% CI 11.0%-32.8%). Externalization followed by shunt removal/new shunt placement (5 [29.4%] of 17; 95% CI 10.3%-56.0%) and nonsurgical management (15 [23.4%] of 64; 95% CI 13.8%-35.7%) had higher, but nonstatistically significant, reinfection rates. The length of stay was shorter for nonsurgical management.Surgical approach to treatment of initial CSF shunt infection was not associated with reinfection in this large cohort of patients.

Background and objective: Latino children have lower rates of injury visits to emergency departments (EDs) than non-Latino white and African American children. This study tests the hypothesis that this difference reflects health insurance status. Design: Secondary analysis. Patients/setting: Children under 19 years of age visiting EDs in the USA, sampled in the National Hospital Ambulatory Medical Care Survey of EDs (NHAMCS-ED) from 1997 to 2001. Main outcome measures: Rates of ED injury visits; ED injury visit rates by race/ethnicity stratified by health insurance and adjusted for other covariates; subtypes of injury visits; and procedures and hospital admissions by race/ethnicity. Results: Injuries accounted for >56 million, or 40.5%, of total ED visits among pediatric patients. Injury visits occurred at lower rates for Latino children (9.9 per 100 person years) than non-Latino white and African American children (16.2 and 18.3, respectively), although total ED visit rates were similar. Regardless of health insurance status, Latino children had lower rates of injury visits than non-Latino white and African American children. Latino children had lower rates of the three major subtypes of injury visits (sports, accidental falls, struck by/between objects). Latino children had similar rates of procedures and hospital admissions to non-Latino white children. Conclusions: Irrespective of their insurance status, Latino children have lower rates of ED injury visits in the USA than non-Latino white children. Possible reasons for this difference include different healthcare seeking behavior or different injury patterns by race/ethnicity, but not differences in health insurance status or barriers to accessing ED care.

The goal of this study was to assess outcomes and costs associated with hospitalist comanagement of medically complex children undergoing spinal fusion surgery for neuromuscular scoliosis.A hospitalist comanagement program was implemented at a children's hospital. We conducted a retrospective case series study of patients during 2003-2008 to compare clinical and cost outcomes for 87 preimplementation patients, 40 patients during a partially implemented program, and 80 patients during a fully implemented program.When compared with preimplementation patients, full implementation program patients did not demonstrate a statistically significant difference in median length of stay on the medical/surgical unit after transfer from the PICU (median: 6 vs 8 days; P = .07). Patients in the full implementation group received fewer days of parenteral nutrition (median: 0 vs 6 days; P = .0006) and had fewer planned and unplanned laboratory studies on the inpatient unit. There was no statistically significant change in returns to the operating room (P = .08 between preimplementation and full implementation), other complications, or 30-day readmissions. Median hospital costs increased from preimplementation ($59372) to partial implementation ($89302) and remained elevated during full implementation ($81 651) compared with preimplementation (P = .004). Mean physician costs followed a similar trajectory from preimplementation ($18425) to partial implementation ($24101) to full implementation ($22578; P = .0006 [versus preimplementation]).A hospitalist comanagement program can significantly affect the care of medically complex children undergoing spinal fusion surgery. Initial program costs may increase.

OBJECTIVES: To characterize the types and external causes of pediatric injury-related visits (IRVs) to emergency departments (EDs), in particular, sports-related injuries. To compare the characteristics of children with IRVs with those with non-IRVs, specifically, differences in IRV rates by race and ethnicity and by health insurance. METHODS: This was a stratified random-sample survey of EDs in the National Hospital Ambulatory Medical Care Survey (NHAMCS), including all IRVs for patients less than 19 years of age in 1998 (n = 2,656). National estimates of pediatric IRVs were obtained using the assigned patient visit weights in the NHAMCS databases and SUDAAN analyses. Measures of association between predictor variables (patient and health insurance characteristics) and whether a child had an IRV were calculated using multivariate logistic regression analyses to determine adjusted odds ratios with 95% confidence intervals. RESULTS: Pediatric IRVs accounted for more than 11 million ED visits annually. The most common diagnoses for IRVs were open wounds, contusions, sprains and strains, and fractures and dislocations. The leading external causes of IRVs were sports-related injuries, accidental falls, being struck by objects, and motor vehicle collisions. Children with IRVs differed from those who presented for non-IRVs in many characteristics: they were more likely to be male, to be older, to be of white race, and to have private insurance, and less likely to be of Asian or Hispanic ethnicity. CONCLUSIONS: Sports and recreation are the leading external causes of pediatric IRVs to EDs in the United States. There are different patterns of IRVs according to gender, age, race, ethnicity, and insurance. Identification of specific patterns of injury is necessary for the design of effective prevention strategies.

Objective To quantify the extent to which cerebrospinal fluid (CSF) shunt revisions are associated with increased risk of CSF shunt infection, after adjusting for patient factors that may contribute to infection risk. Study design We used the Hydrocephalus Clinical Research Network registry to assemble a large prospective 6-center cohort of 1036 children undergoing initial CSF shunt placement between April 2008 and January 2012. The primary outcome of interest was first CSF shunt infection. Data for initial CSF shunt placement and all subsequent CSF shunt revisions prior to first CSF shunt infection, where applicable, were obtained. The risk of first infection was estimated using a multivariable Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HRs) with 95% CI. Results Of the 102 children who developed first infection within 12 months of placement, 33 (32%) followed one or more CSF shunt revisions. Baseline factors independently associated with risk of first infection included: gastrostomy tube (HR 2.0, 95% CI, 1.1, 3.3), age 6-12 months (HR 0.3, 95% CI, 0.1, 0.8), and prior neurosurgery (HR 0.4, 95% CI, 0.2, 0.9). After controlling for baseline factors, infection risk was most significantly associated with the need for revision (1 revision vs none, HR 3.9, 95% CI, 2.2, 6.5; ≥2 revisions, HR 13.0, 95% CI, 6.5, 24.9). Conclusions This study quantifies the elevated risk of infection associated with shunt revisions observed in clinical practice. To reduce risk of infection risk, further work should optimize revision procedures.