RESUMO

OBJECTIVES: To describe hospital-based asthma-specific discharge components at children's hospitals and determine the association of these discharge components with pediatric asthma readmission rates. STUDY DESIGN: This is a multicenter retrospective cohort study of pediatric asthma hospitalizations in 2015 at children's hospitals participating in the Pediatric Health Information System. Children ages 5 to 17 years were included. An electronic survey assessing 13 asthma-specific discharge components was sent to quality leaders at all 49 hospitals. Correlations of combinations of asthma-specific discharge components and adjusted readmission rates were calculated. RESULTS: The survey response rate was 92% (45 of 49 hospitals). Thirty-day and 3-month adjusted readmission rates varied across hospitals, ranging from 1.9% to 3.9% for 30-day readmissions and 5.7% to 9.1% for 3-month readmissions. No individual or combination discharge components were associated with lower 30-day adjusted readmission rates. The only single-component significantly associated with a lower rate of readmission at 3 months was having comprehensive content of education (P < .029). Increasing intensity of discharge components in bundles was associated with reduced adjusted 3-month readmission rates, but this did not reach statistical significance. This was seen in a 2-discharge component bundle including content of education and communication with the primary medical doctor, as well as a 3-discharge component bundle, which included content of education, medications in-hand, and home-based environmental mitigation. CONCLUSIONS: Children's hospitals demonstrate a range of asthma-specific discharge components. Although we found no significant associations for specific hospital-level discharge components and asthma readmission rates at 30 days, certain combinations of discharge components may support hospitals to reduce healthcare utilization at 3 months.

Assuntos

RESUMO

OBJECTIVE: 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. STUDY DESIGN: 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. RESULTS: 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). CONCLUSIONS: 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.

Assuntos

Assuntos

RESUMO

OBJECTIVES: To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals. STUDY DESIGN: Multicenter retrospective cohort analysis of 12,449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals. RESULTS: In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥ 12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively. CONCLUSIONS: Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

Assuntos

RESUMO

OBJECTIVES: To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. STUDY DESIGN: This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. RESULTS: 40,257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. CONCLUSIONS: Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care.

Assuntos

Assuntos

RESUMO

OBJECTIVE: To determine the association between institutional inpatient clinical practice guidelines (CPGs) for bronchiolitis and the use of diagnostic tests and treatments. STUDY DESIGN: A multicenter retrospective cohort study of infants aged 29 days to 24 months with a discharge diagnosis of bronchiolitis was conducted between July 2011 and June 2012. An electronic survey was sent to quality improvement leaders to determine the presence, duration, and method of CPG implementation at participating hospitals. The Wilcoxon rank-sum test was used to perform bivariate comparisons between hospitals with CPGs and those without CPGs. Multivariable analysis was used to determine associations between CPG characteristics and the use of tests and treatments; analyses were clustered by hospital. RESULTS: The response rate to our electronic survey was 77% (33 of 43 hospitals). The majority (85%) had an institutional bronchiolitis CPG in place. Hospitals with a CPG had universal agreement regarding recommendations against routine tests and treatments. The presence of a CPG was not associated with significant reductions in the use of tests and treatments (eg, complete blood count, chest radiography, bronchodilator use, steroid and antibiotic use). A longer interval duration since CPG implementation and presence of an easily accessible online CPG document were associated with significant reductions in the performance of complete blood count and chest radiography and the use of corticosteroids. Other implementation factors demonstrated mixed results. CONCLUSION: Most children's hospitals have an institutional bronchiolitis CPG in place. The content of these CPGs is largely uniform in practice recommendations against tests and treatments. The presence of institutional CPGs did not significantly reduce the ordering of tests and treatments. Online accessibility of a written CPG and prolonged duration of implementation reduce tests and treatments.

Assuntos

RESUMO

OBJECTIVE: To assess whether children with influenza who are exposed to secondhand tobacco smoke (SHS) would have more severe illness than those not exposed. STUDY DESIGN: We abstracted charts from pediatric inpatients with confirmed influenza from 2002-2009 for demographics, medical history, and smoke exposure. Severity indicators included intensive care, intubation, and length of stay (LOS) in the hospital; potential confounding factors included demographics and the presence of asthma or chronic conditions. All χ(2), t tests, and regression analyses were run using SPSS v. 18.0. RESULTS: Of 117 children, 40% were exposed to SHS, who had increased need for intensive care (30% vs 10%, P < .01) and intubation (13% vs 1%, P < .05), and had longer LOS (4.0 vs 2.4 days, P < .01). Children with chronic conditions and SHS exposure required more intensive care (53% vs 18%, P < .05) and had longer LOS (10.0 vs 3.5 days, P < .01) than children not exposed to SHS with chronic conditions. In multivariate analyses controlling for potential confounding factors, children with SHS exposure were 4.7 times more likely to be admitted to intensive care (95% CI 1.4-18.5) and had a 70% longer LOS (95% CI 12%-230%). CONCLUSIONS: Children with SHS exposure who are hospitalized with influenza have more severe illness. Efforts are needed to immunize this population against influenza, and eliminate children's exposure to SHS.

Assuntos