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Objective To assess the performance of previously published high-intensity neurologic impairment (NI) diagnosis codes in identification of hospitalized children with clinical NI. Methods Retrospective study of 500 randomly selected discharges in 2019 from a freestanding children's hospital. All charts were reviewed for 1) NI discharge diagnosis codes and 2) documentation of clinical NI (a neurologic diagnosis and indication of functional impairment like medical technology). Test statistics of clinical NI were calculated for discharges with and without an NI diagnosis code. A sensitivity analysis varied the threshold for “substantial functional impairment.” Secondary analyses evaluated misclassified discharges and a more stringent definition for NI. Results Diagnosis codes identified clinically documented NI with 88.1% (95% confidence interval [CI]: 84.7, 91) specificity, and 79.4% (95% CI: 67.3, 88.5) sensitivity; negative predictive value (NPV) was 96.7% (95% CI: 94.8, 98.0), and positive predictive value (PPV) was 49% (95% CI: 42, 56.1). Including children with milder functional impairment (lower threshold) resulted in NPV of 95.7% and PPV of 77.5%. Restricting to children with more severe functional impairment (higher threshold) resulted in NPV of 98.2% and PPV of 44.1%. Misclassification was primarily due to inclusion of children without functional impairments. A more stringent NI definition including diagnosis codes for NI and feeding tubes had a specificity of 98.4% (95% CI: 96.7–99.3) and sensitivity of 28.6% (19.4–41.3). Conclusions All scenarios evaluated demonstrated high NPV and low-to-moderate PPV of the diagnostic code list. To maximize clinical utility, NI diagnosis codes should be used with strategies to mitigate the risk of misclassification.

Aim To identify the highest-priority clinical research areas related to children with neurological impairment and medical complexity among clinicians and caregivers. Method A modified, three-stage Delphi study using online surveys and guided by a steering committee was completed. In round 1, clinicians and family caregivers suggested clinical topics and related questions that require research to support this subgroup of children. After refinement of the suggestions by the steering committee, participants contributed to 1 (family caregivers) or 2 (clinicians) subsequent rounds to develop a prioritized list. Results A diverse international expert panel consisting of 49 clinicians and 12 family caregivers provided 601 responses. Responses were distilled into 26 clinical topics comprising 126 related questions. The top clinical topics prioritized for research were irritability and pain, child mental health, disorders of tone, polypharmacy, sleep, aspiration, behavior, dysautonomia, and feeding intolerance. The clinician expert panel also prioritized 10 specific research questions. Interpretation Study findings support a research agenda for children with neurological impairment and medical complexity focused on addressing clinical questions, prioritized by an international group of clinicians and caregivers.

Background Children who require chronic positive pressure ventilation (CPPV) are frequently hospitalized with acute respiratory infections. Although respiratory viral testing is often performed, it is unclear how positive results impact antibiotic use. We sought to assess the impact of respiratory viral testing on antibiotic use in hospitalized children on CPPV. Methods This retrospective cohort study included hospitalized children on CPPV who had respiratory viral polymerase chain reaction (RVP) testing on admission. Primary exposure was a positive RVP result; primary outcome was antibiotic de-escalation, defined as discontinuation of antibiotics or narrowing of antimicrobial spectra. To determine the independent association of positive RVP and antibiotic de-escalation, a generalized linear mixed effect model was used to account for within patient clustering and confounders defined a priori (blood and respiratory cultures, leukocytosis, bandemia, chest radiograph findings, aspiration risk, and recent admission). Results A total of 200 admissions representing 118 patients were included. A viral pathogen was identified in 46.5% (93/200) of admissions; rhinovirus was most frequently identified (61.5% of positive RVPs). Antibiotic de-escalation occurred in 33% of admissions (35.5% of RVP-positive admissions vs 30.8% of RVP-negative admissions; P = .49). In adjusted analysis, there was no association between positive RVP and antibiotics de-escalation (adjusted OR: 0.86; 95% confidence interval: 0.32-2.26). Conclusion This single center cohort study suggests that respiratory viral testing may not impact antibiotic prescribing for hospitalized children on CPPV. There is need for improved stewardship of both diagnostic testing and antimicrobial use in this population.

OBJECTIVES To examine bacterial respiratory cultures in children with neurologic impairment (NI) (eg, cerebral palsy), both with and without tracheostomies, who were hospitalized with acute respiratory infections (ARIs) (eg, pneumonia) and to compare culture results across hospitals and age groups. METHODS This multicenter retrospective cohort study included ARI hospitalizations for children aged 1 to 18 years with NI between 2007 and 2012 who had a bacterial respiratory culture obtained within 2 days of admission. Data from 5 children’s hospitals in the Pediatric Health Information System Plus database were used. Organisms consistent with oral flora and nonspeciated organisms were omitted from analysis. The prevalence of positive respiratory culture results and the prevalence of organisms identified were compared across hospitals and age groups and in subanalyses of children with and without tracheostomies by using generalized estimating equations to account for within-patient clustering. RESULTS Of 4900 hospitalizations, 693 from 485 children had bacterial respiratory cultures obtained. Of these, 54.5% had positive results, although this varied across hospitals (range 18.6%–83.2%; P < .001). Pseudomonas aeruginosa and Staphylococcus aureus were the most commonly identified organisms across hospitals and age groups and in patients with and without tracheostomies. Large variation in growth prevalence was identified across hospitals but not age groups. CONCLUSIONS The bacteriology of ARI in hospitalized children with NI differs from that of otherwise healthy children. Significant variation in prevalence of positive bacterial respiratory culture results and organism growth were observed across hospitals, which may be secondary to local environmental factors and microbiology reporting practices.

BACKGROUND AND OBJECTIVES Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%. METHODS Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish. RESULTS During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months. CONCLUSIONS Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.

OBJECTIVES To identify independent predictors of and derive a risk score for invasive herpes simplex virus (HSV) infection. METHODS In this 23-center nested case-control study, we matched 149 infants with HSV to 1340 controls; all were ≤60 days old and had cerebrospinal fluid obtained within 24 hours of presentation or had HSV detected. The primary and secondary outcomes were invasive (disseminated or central nervous system) or any HSV infection, respectively. RESULTS Of all infants included, 90 (60.4%) had invasive and 59 (39.6%) had skin, eyes, and mouth disease. Predictors independently associated with invasive HSV included younger age (adjusted odds ratio [aOR]: 9.1 [95% confidence interval (CI): 3.4–24.5] 28 days), prematurity (aOR: 2.3, 95% CI: 1.1 to 5.1), seizure at home (aOR: 6.1, 95% CI: 2.3 to 16.4), ill appearance (aOR: 4.2, 95% CI: 2.0 to 8.4), abnormal triage temperature (aOR: 2.9, 95% CI: 1.6 to 5.3), vesicular rash (aOR: 54.8, (95% CI: 16.6 to 180.9), thrombocytopenia (aOR: 4.4, 95% CI: 1.6 to 12.4), and cerebrospinal fluid pleocytosis (aOR: 3.5, 95% CI: 1.2 to 10.0). These variables were transformed to derive the HSV risk score (point range 0–17). Infants with invasive HSV had a higher median score (6, interquartile range: 4–8) than those without invasive HSV (3, interquartile range: 1.5–4), with an area under the curve for invasive HSV disease of 0.85 (95% CI: 0.80–0.91). When using a cut-point of ≥3, the HSV risk score had a sensitivity of 95.6% (95% CI: 84.9% to 99.5%), specificity of 40.1% (95% CI: 36.8% to 43.6%), and positive likelihood ratio 1.60 (95% CI: 1.5 to 1.7) and negative likelihood ratio 0.11 (95% CI: 0.03 to 0.43). CONCLUSIONS A novel HSV risk score identified infants at extremely low risk for invasive HSV who may not require routine testing or empirical treatment.

BACKGROUND: Children with neurologic impairment (NI) are at risk for developing co-occurring chronic conditions, increasing their medical complexity and morbidity. We assessed the prevalence and timing of onset for those conditions in children with NI. METHODS: This longitudinal analysis included 6229 children born in 2009 and continuously enrolled in Medicaid through 2015 with a diagnosis of NI by age 3 in the IBM Watson Medicaid MarketScan Database. NI was defined with an existing diagnostic code set encompassing neurologic, genetic, and metabolic conditions that result in substantial functional impairments requiring subspecialty medical care. The prevalence and timing of co-occurring chronic conditions was assessed with the Agency for Healthcare Research and Quality Chronic Condition Indicator system. Mean cumulative function was used to measure age trends in multimorbidity. RESULTS: The most common type of NI was static (56.3%), with cerebral palsy (10.0%) being the most common NI diagnosis. Respiratory (86.5%) and digestive (49.4%) organ systems were most frequently affected by co-occurring chronic conditions. By ages 2, 4, and 6 years, the mean (95% confidence interval [CI]) numbers of co-occurring chronic conditions were 3.7 (95% CI 3.7–3.8), 4.6 (95% CI 4.5–4.7), and 5.1 (95% CI 5.1–5.2). An increasing percentage of children had ≥9 co-occurring chronic conditions as they aged: 5.3% by 2 years, 10.0% by 4 years, and 12.8% by 6 years. CONCLUSIONS: Children with NI enrolled in Medicaid have substantial multimorbidity that develops early in life. Increased attention to the timing and types of multimorbidity in children with NI may help optimize their preventive care and case management health services.

Objective To compare hospital outcomes associated with commonly used antibiotic therapies for aspiration pneumonia in children with neurologic impairment (NI). Design/methods A retrospective study of children with NI hospitalized with aspiration pneumonia at 39 children's hospitals in the Pediatric Health Information System database. Exposure was empiric antibiotic therapy classified by antimicrobial activity. Outcomes included acute respiratory failure, intensive care unit (ICU) transfer, and hospital length of stay (LOS). Multivariable regression evaluated associations between exposure and outcomes and adjusted for confounders, including medical complexity and acute illness severity. Results In the adjusted analysis, children receiving Gram-negative coverage alone had two-fold greater odds of respiratory failure (odds ratio [OR] 2.15; 95% CI: 1.41-3.27), greater odds of ICU transfer (OR 1.80; 95% CI: 1.03-3.14), and longer LOS [adjusted rate ratio (RR) 1.28; 95% CI: 1.16-1.41] than those receiving anaerobic coverage alone. Children receiving anaerobic and Gram-negative coverage had higher odds of respiratory failure (OR 1.65; 95% CI: 1.19-2.28) than those receiving anaerobic coverage alone, but ICU transfer (OR 1.15; 95% CI: 0.73-1.80) and length of stay (RR 1.07; 95% CI: 0.98-1.16) did not statistically differ. For children receiving anaerobic, Gram-negative, and P. aeruginosa coverage, LOS was shorter (RR 0.83; 95% CI: 0.76-0.90) than those receiving anaerobic coverage alone; odds of respiratory failure and ICU transfer rates did not significantly differ. Conclusions Anaerobic therapy appears to be important in the treatment of aspiration pneumonia in children with NI. While Gram-negative coverage alone was associated with worse outcomes, its addition to anaerobic therapy may not yield improved outcomes.

BACKGROUND: Children with neurologic impairment (NI) are commonly hospitalized with acute respiratory infections (ARI). These children frequently require respiratory support at baseline and are often discharged before return to respiratory baseline. OBJECTIVE: To determine if discharge before return to respiratory baseline is associated with reutilization among children with NI hospitalized with ARI. METHODS: This single-center retrospective cohort study included children with NI aged 1 to 18 years hospitalized with ARI who required increased respiratory support between January 2010 and September 2015. The primary exposure was discharge before return to respiratory baseline. The primary outcome was 30-day hospital reutilization. A generalized estimating equation was used to examine the association between exposure and outcome while accounting for within-patient clustering and patient-level clinical complexity and illness severity. RESULTS: In the 632 hospitalizations experienced by 366 children, children were discharged before return to respiratory baseline in 30.4% of hospitalizations. Compared with those hospitalizations in which children were discharged at baseline, hospitalizations with a discharge before return to respiratory baseline were more likely to be for privately insured, technology-dependent children with respiratory comorbidities. Compared with discharges at respiratory baseline, discharges with increased respiratory support had no difference in 30-day reutilization (32.8% vs 31.8%; P = .81; adjusted OR 0.80, 95% CI 0.51-1.26). CONCLUSIONS: Among children with NI hospitalized with ARI, discharge before return to respiratory baseline was common, but it was not associated with hospital reutilization. Return to respiratory baseline may not be a necessary component of discharge criteria in this population.

This cross-sectional study describes and evaluates the effectiveness of a refined coding system for distinguishing children with high-intensity neurological impairment from those with lower-intensity neurological conditions.

Wheezing is common in preschool-aged children (ages 2-5 years), with up to half in this age group having experienced a wheezing episode and up to one-third, recurrent wheezing.1,2 Young children with wheezing require ED visits and hospitalizations at much higher rates than older children and adults.3 Several studies have also demonstrated that children in this age group have higher rates of SCS prescriptions compared with older children.4,5 Despite the high prevalence of wheezing in this age group, there is great heterogeneity in the etiology and clinical progression of early childhood wheezing, with up to six described phenotypes each with varying levels of association with the development of asthma.6 Given the high frequency of asthma, preschool-aged children admitted with wheezing are often treated with SCS, as this is the standard of care for an acute asthma exacerbation.7

BACKGROUND AND OBJECTIVES: Little is known about the use of chronic medications (CMs) in children. We assessed the prevalence of CM use in children and the association of clinical characteristics and health care resource use with the number of CMs used. METHODS: This is a retrospective study of children ages 1 to 18 years using Medicaid from 10 states in 2014 grouped by the annual number of CMs (0, 1, 2–4, 5–9, and ≥10 medications), which are defined as a dispensed ≥30-day prescription with ≥2 dispensed refills. Trends in clinical characteristics and health care use by number of CMs were evaluated with the Cochran-Armitage trend test. RESULTS: Of 4 594 061 subjects, 18.8% used CMs. CM use was 44.4% in children with a complex chronic condition. Across all children, the most common CM therapeutic class was neurologic (28.9%). Among CM users, 48.8% used multiple CMs (40.3% used 2–4, 7.0% used 5–9, and 0.5% used ≥10). The diversity of medications increased with increasing number of CMs: for 1 CM, amphetamine stimulants were most common (29.0%), and for ≥10 CMs, antiepileptics were most common (7.1%). Of $2.3 billion total pharmacy spending, 59.3% was attributable to children dispensed multiple CMs. Increased CM use (0 to ≥10 medications) was associated with increased emergency department use (32.1% to 56.2%) and hospitalization (2.3% to 36.7%). CONCLUSIONS: Nearly 1 in 5 children with Medicaid used CMs. Use of multiple CMs was common and correlated with increased health care use. Understanding CM use in children should be fundamentally important to health care systems when strategizing how to provide safe, evidence-based, and cost-effective pharmaceutical care to children.

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

To determine age-stratified prevalence of concomitant bacterial meningitis in infants ≤60 days with a urinary tract infection, we performed a 23-center, retrospective study of 1737 infants with urinary tract infection. Concomitant bacterial meningitis was rare, but more common in infants 0-28 days of age [0.9%; 95% confidence interval (CI): 0.4%-1.9%) compared with infants 29-60 days of age (0.2%; 95% CI: 0%-0.8%).

To compare health care use and spending in children using vs not using respiratory medical equipment and supplies (RMES).Cohort study of 20 352 children age 1-18 years continuously enrolled in Medicaid in 2013 from 12 states in the Truven Medicaid MarketScan Database; 7060 children using RMES were propensity score matched with 13 292 without RMES. Home RMES use was identified with Healthcare Common Procedure Coding System and International Classification of Diseases codes. RMES use was regressed on annual per-member-per-year Medicaid payments, adjusting for demographic and clinical characteristics, including underlying respiratory and other complex chronic conditions.Of children requiring RMES, 47% used oxygen, 28% suction, 22% noninvasive positive-pressure ventilation, 17% tracheostomy, 8% ventilator, 5% mechanical in-exsufflator, and 4% high-frequency chest wall oscillator. Most children (93%) using RMES had a chronic condition; 26% had ≥6. The median per-member-per-year payments in matched children with vs without RMES were $24 359 vs $13 949 (P .001). In adjusted analyses, payment increased significantly (P .001 for all) with mechanical in-exsufflator (+$2657), tracheostomy (+$6447), suction (+$7341), chest wall oscillator (+$8925), and ventilator (+$20 530). Those increased payments were greater than the increase associated with a coded respiratory chronic condition (+$2709). Hospital and home health care were responsible for the greatest differences in payment (+$3799 and +$3320, respectively) between children with and without RMES.The use of RMES is associated with high health care spending, especially with hospital and home health care. Population health initiatives in children may benefit from consideration of RMES in comprehensive risk assessment for health care spending.

OBJECTIVES: To determine age-specific reference values and quantify age-related changes for cerebrospinal fluid (CSF) white blood cell (WBC) counts and protein and glucose concentrations in infants ≤60 days of age. METHODS: This multicenter, cross-sectional study included infants ≤60 days old with CSF cultures and complete CSF profiles obtained within 24 hours of presentation. Those with conditions suspected or known to cause abnormal CSF parameters (eg, meningitis) and those with a hospital length of stay of >72 hours were excluded. Reference standards were determined for infants ≤28 days of age and 29 to 60 days of age by using the third quartile +1.5 interquartile range for WBC and protein and the first quartile −1.5 interquartile range for glucose. CSF parameter centile curves based on age were calculated by using the LMST method. RESULTS: A total of 7766 patients were included. CSF WBC counts were higher in infants ≤28 days of age (upper bound: 15 cells/mm3) than in infants 29 to 60 days of age (upper bound: 9 cells/mm3; P < .001). CSF protein concentrations were higher in infants ≤28 days of age (upper bound: 127 mg/dL) than in infants 29 to 60 days of age (upper bound: 99 mg/dL; P < .001). CSF glucose concentrations were lower in infants ≤28 days of age (lower bound: 25 mg/dL) than in infants 29 to 60 days of age (lower bound: 27 mg/dL; P < .001). CONCLUSIONS: The age-specific CSF WBC count, protein concentration, and glucose concentration reference values identified in this large, multicenter cohort of infants can be used to interpret the results of lumbar puncture in infants ≤60 days of age.

BACKGROUND: Although neonatal herpes simplex virus (HSV) is a potentially devastating infection requiring prompt evaluation and treatment, large-scale assessments of the frequency in potentially infected infants have not been performed. METHODS: We performed a retrospective cross-sectional study of infants ≤60 days old who had cerebrospinal fluid culture testing performed in 1 of 23 participating North American emergency departments. HSV infection was defined by a positive HSV polymerase chain reaction or viral culture. The primary outcome was the proportion of encounters in which HSV infection was identified. Secondary outcomes included frequency of central nervous system (CNS) and disseminated HSV, and HSV testing and treatment patterns. RESULTS: Of 26 533 eligible encounters, 112 infants had HSV identified (0.42%, 95% confidence interval [CI]: 0.35%–0.51%). Of these, 90 (80.4%) occurred in weeks 1 to 4, 10 (8.9%) in weeks 5 to 6, and 12 (10.7%) in weeks 7 to 9. The median age of HSV-infected infants was 14 days (interquartile range: 9–24 days). HSV infection was more common in 0 to 28-day-old infants compared with 29- to 60-day-old infants (odds ratio 3.9; 95% CI: 2.4–6.2). Sixty-eight (0.26%, 95% CI: 0.21%–0.33%) had CNS or disseminated HSV. The proportion of infants tested for HSV (35%; range 14%–72%) and to whom acyclovir was administered (23%; range 4%–53%) varied widely across sites. CONCLUSIONS: An HSV infection was uncommon in young infants evaluated for CNS infection, particularly in the second month of life. Evidence-based approaches to the evaluation for HSV in young infants are needed.

This cohort study examines the incidence, risk factors, and types of infection in long-term care facilities for children and young adults.

BACKGROUND Recent national guidelines recommend use of narrow-spectrum antibiotic therapy as empiric treatment for children hospitalized with community-acquired pneumonia (CAP). However, clinical outcomes associated with adoption of this recommendation have not been studied. METHODS This retrospective cohort study included children age 3 months to 18 years, hospitalized with CAP from May 2, 2011 through July 30, 2012. Primary exposure of interest was empiric antibiotic therapy, classified as guideline recommended or not. Primary outcomes were length of stay (LOS), total hospital costs, and inpatient pharmacy costs. Secondary outcomes included broadened antibiotic therapy, emergency department revisits, and readmissions. Multivariable linear regression and Fisher exact test were performed to determine the association of guideline-recommended antibiotic therapy on outcomes. RESULTS Empiric guideline-recommended therapy was prescribed to 168 (76%) of 220 patients. Median hospital LOS was 1.3 days (interquartile range [IQR]: 0.9–1.9 days), median total cost of index hospitalization was $4097 (IQR: $2657–$6054), and median inpatient pharmacy cost was $91 (IQR: $40–$183). Between patients who did and did not receive guideline-recommended therapy, there were no differences in LOS (adjusted −5.8% change; 95% confidence interval [CI]: −22.1 to 12.8), total costs (adjusted −10.9% change; 95% CI: −27.4 to 9.4), or inpatient pharmacy costs (adjusted 14.8% change; 95% CI: −43.4 to 27.1). Secondary outcomes were rare, with no difference in unadjusted analysis between patients who did and did not receive guideline-recommended therapy. CONCLUSIONS Use of guideline-recommended antibiotic therapy was not associated with unintended negative consequences; there were no changes in LOS, total costs, or inpatient pharmacy costs. Journal of Hospital Medicine 2015;10:13–18. © 2014 Society of Hospital Medicine

* Abbreviations: CCC — : complex chronic condition CMC — : children with medical complexity The prevalence of children with medical complexity (CMC) has increased in recent decades.1,2 This increase is attributable, in part, to advances in medical care that improved survival of children with chronic, congenital, or critical illnesses. These children account for a disproportionate amount of inpatient utilization. Among 6.9 million pediatric discharges in 2006, just 10.1% of pediatric admissions included children with complex chronic conditions (CCC)3; however, these admissions accounted for 26.1% of pediatric hospital days and 40.6% of pediatric hospital charges.3 Few data, however, examine variability of utilization across health care systems. In this issue of Pediatrics , Ralston et al,4 by using an all payer claims database, examine variation in health care utilization in a population-based cohort of CMC across 4 children’s hospitals in New England. This cohort was defined based on revised CCC discharge diagnosis codes3 further refined to minimize bias by excluding children with disease processes necessitating care at 1 specific hospital (eg, bone marrow transplantation). Claims data provided information on utilization across the continuum of care. Health care encounters, imaging … Address correspondence to Samir S. Shah, MD, 3333 Burnet Ave, ML 9016, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229. E-mail: samir.shah{at}cchmc.org

To compare the timing and magnitude of variation of pediatric readmission rates across race/ethnicity for selected chronic conditions: asthma, diabetes, seizures, migraines, and depression.Retrospective analysis of hospitalizations at 48 children's hospitals in the 2013 Pediatric Health Information System database for children (ages 0-18 years) admitted for asthma (n = 36 910), seizure (n = 35 361), diabetes (n = 12 468), migraine (n = 5882), and depression (n = 5132). Generalized linear models with a random effect for hospital were used to compare the likelihood of readmission by patients' race/ethnicity, adjusting for severity of illness, age, payer, and medical complexity. Adjusted readmission rates were calculated by week over 1 year.Significant variation in adjusted readmission rates by race/ethnicity existed for conditions aside from depression. Disparities for diabetes and asthma emerged at 3 and 4 weeks, respectively; they remained divergent up to 1 year with the highest 1-year readmission rates in non-Hispanic blacks vs other race/ethnicities (diabetes: 21.7% vs 13.4%, P .001; asthma: 21.4% vs 14.6%, P .001). Disparities for migraines and seizure emerged at 6 and 7 weeks, respectively; they remained up to 1 year, with the highest 1-year readmission rates in non-Hispanic whites vs other race/ethnicities (migraine: 17.3% vs 13.6%, P .001; seizure: 23.9% vs 21.9%, P .001).Readmission disparities behave differently across chronic conditions. They emerge more quickly after discharge for children hospitalized with asthma or diabetes than for seizures or migraines. The highest readmission rates were not consistently observed for 1 particular race/ethnicity. Study findings can impact pediatric chronic disease management to improve care for children with these conditions.

BACKGROUND AND OBJECTIVE: Children with neurologic impairment (NI) are commonly hospitalized for different types of pneumonia, including aspiration pneumonia. We sought to compare hospital management and outcomes of children with NI diagnosed with aspiration versus nonaspiration pneumonia. METHODS: A retrospective study of 27 455 hospitalized children aged 1 to 18 years with NI diagnosed with pneumonia from 2007 to 2012 at 40 children’s hospitals in the Pediatric Health Information System database. The primary exposure was pneumonia type, classified as aspiration or nonaspiration. Outcomes were complications (eg, acute respiratory failure) and hospital utilization (eg, length of stay, 30-day readmission). Multivariable regression was used to assess the association between pneumonia type and outcomes, adjusting for NI type, comorbid conditions, and other characteristics. RESULTS: In multivariable analysis, the 9.7% of children diagnosed with aspiration pneumonia experienced more complications than children with nonaspiration pneumonia (34.0% vs 15.2%, adjusted odds ratio [aOR] 1.2 (95% confidence interval [CI] 1.1–1.3). Children with aspiration pneumonia had significantly longer length of stay (median 5 vs 3 days; ratio of means 1.2; 95% CI 1.2–1.3); more ICU transfers (4.3% vs 1.5%; aOR 1.4; 95% CI 1.1–1.9); greater hospitalization costs (median $11 594 vs $5162; ratio of means 1.2; 95% CI 1.2–1.3); and more 30-day readmissions (17.4% vs 6.8%; aOR 1.3; 95% CI 1.2–1.5). CONCLUSIONS: Hospitalized children with NI diagnosed with aspiration pneumonia have more complications and use more hospital resources than when diagnosed with nonaspiration pneumonia. Additional investigation is needed to understand the reasons for these differences.

BACKGROUND AND OBJECTIVE:A national evidence-based guideline for the management of community-acquired pneumonia (CAP) in children recommends blood cultures for patients admitted with moderate to severe illness. Our primary aim was to increase ordering of blood cultures for children hospitalized with CAP from 53% to 90% in 6 months. The secondary aim was to evaluate the effect of obtaining blood cultures on length of stay (LOS).METHODS:At a tertiary children’s hospital, interventions to increase blood cultures focused on 3 key drivers and were tested separately in the emergency department and inpatient units by using multiple plan-do-study-act cycles. The impact of the interventions was tracked over time on run charts. The association of ordering blood cultures and LOS was estimated by using linear regression models.RESULTS:Within 6 months, the percentage of patients admitted with CAP who had blood cultures ordered increased from 53% to 100%. This change has been sustained for 12 months. Overall, 239 (79%) of the 303 included patients had a blood culture ordered; of these, 6 (2.5%) were positive. Patients who had a blood culture did not have an increased LOS compared with those without a blood culture.CONCLUSIONS:Quality improvement methods were used to increase adherence to evidence-based national guidelines for performing blood cultures on children hospitalized with CAP; LOS did not increase. These results support obtaining blood cultures on all patients admitted with CAP without negative effects on LOS in a setting with a reliably low false-positive blood culture rate.

OBJECTIVE: In August 2011, the Pediatric Infectious Disease Society and Infectious Disease Society of America published an evidence-based guideline for the management of community-acquired pneumonia (CAP) in children ≥3 months. Our objective was to evaluate if quality improvement (QI) methods could improve appropriate antibiotic prescribing in a setting without a formal antimicrobial stewardship program. METHODS: At a tertiary children’s hospital, QI methods were used to rapidly implement the Pediatric Infectious Disease Society/Infectious Disease Society of America guideline recommendations for appropriate first-line antibiotic therapy in children with CAP. QI interventions focused on 4 key drivers and were tested separately in the emergency department and on the hospital medicine resident teams, using multiple plan-do-study-act cycles. Medical records of eligible patients were reviewed weekly to determine the success of prescribing recommended antibiotic therapy. The impact of these interventions on our outcome was tracked over time on run charts. RESULTS: Appropriate first-line antibiotic prescribing for children admitted with the diagnosis of CAP increased in the emergency department from a median baseline of 0% to 100% and on the hospital medicine resident teams from 30% to 100% within 6 months of introducing the guidelines locally at Cincinnati Children’s Hospital Medical Center and has been sustained for 3 months. CONCLUSIONS: Our study demonstrates that QI methods can rapidly improve adherence to national guidelines even in settings without a formal antimicrobial stewardship program to encourage judicious antibiotic prescribing for CAP.

Objective To assess hospital-level variability in diagnostic testing and outcomes for children with neurologic impairment hospitalized with pneumonia. Study design A retrospective cohort study of 27 455 children ages 1-18 years with neurologic impairment hospitalized with pneumonia at 39 children's hospitals. K-means clustering was used to assign each hospital to 1 of 3 groups (termed A, B, and C) based on similar diagnostic testing patterns. Outcomes of hospital-level median length of stay (LOS), 30-day readmissions, and pneumonia-associated complications were compared while controlling for patient differences. Results Overall, 48.5% had comorbid complex chronic conditions, and 25.4% were assisted with medical technology. Outcomes and diagnostic testing varied across hospitals: median hospital-level LOS, 3.2 days (IQR 2.8-3.8); median readmission, 8.4% (IQR 6.8,-10.0); and median pneumonia-associated complication rate, 23.1% (IQR 18.7-26.8). Despite similar populations, hospitals in group A tended to perform fewer tests than those in groups B and C. Across hospital groups, there was a significant difference in adjusted readmission rates (group A 7.2%, group B 9.0%, group C 7.7%, P = .003). There was no significant difference in adjusted median LOS (group A 3.4 days, group B 3.2 days, group C 3.3 days, P = .3) or adjusted pneumonia-associated complication rates (group A 22.5%, group B 22.5%, group C 25.0%, P = .6). Conclusions For children with neurologic impairment hospitalized with pneumonia, across hospital differences in diagnostic testing were not associated with clinically meaningful differences in outcomes. High-utilizing hospitals may be able to decrease diagnostic testing for children with neurologic impairment hospitalized with pneumonia without adversely impacting outcomes.

Background In December 2008, the Institute of Medicine (IOM) released the report of a consensus committee recommending added limits on resident duty hours. Methods Perceptions of interns participating in a 1-month trial implementation of the IOM-recommended duty hour limits in one large pediatric residency program during March 2009 were aggregated. Results Interns experienced benefits from the shift-based schedule, including reduced hours and more nights at home. These were accompanied by shortcomings of the new schedule, most prominently increased intensity during the hours worked, weaknesses in sign-outs and handing off of tasks, and inability to know and “own” all patients on the interns' team. The experiment also changed the role and the level of engagement expected from attending physicians. Conclusions The trial implementation of the IOM-recommended limits highlighted that to adapt to additional reduction in hours, residency education needs a significant culture change, including better sign-outs, improved organization of bedside and didactic education, and attention to the added work intensity of a team-based model with daily admissions. Ultimately this may require an adjustment in residents' workload and different expectations and models of support from attending physicians.

Background There has been no sound evidence on the status and dynamics of Libya’s HIV-epidemic, which is urgently needed to inform near-term policy making while the window of opportunity to act is still open. With funding from the European Union we therefore aimed to assess HIV prevalence and related risk factors among populations most vulnerable to HIV. Methods Using respondent-driven sampling, we conducted a cross-sectional survey among 328 people who inject drugs (PWID), 227 men having sex with men (MSM), and 69 female sex workers (FSW) in Tripoli. We collected behavioural data and blood samples for HIV, hepatitis C and B testing. Results We estimated HIV-prevalence of 87% among PWID, 3% among MSM, and 16% among FSW. We detected high levels of IDU-related, and sexual risk factors, in the context of strong stigma and lack of prevention programmes. Of particular concern, 85% of PWID reported having shared needles, only 21% of MSM used a condom at last sex, and 28% of FSW experienced STI symptoms during the last year. Over a third of MSM had risky sex with men and women and nearly a third of FSW had 50 or more sexual partners in the past six months. Conclusion In this first bio-behavioural survey in Libya we detected among PWID one of the highest (or even the highest) levels of HIV-infection worldwide in the absence of a comprehensive harm-reduction programme. There is urgent need to implement an effective National HIV-Strategy informed by the results of this research, and designed to account for the overlap of high-risk sexual and drug-using networks. The risk of further transmission within different risk groups and to the general population is particularly high given the recent military events that led to increased violence, migration, and the disruption of essential HIV-related services and structures.