Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals.

Importance: The scope of low-value care in children's hospitals is poorly understood. Objective: To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants: This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures: Eligible condition-specific hospital encounters. Main Outcomes and Measures: The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results: There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance: This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Incidence and treatment of hypertension in the neonatal intensive care unit.

The incidence and risk factors for hypertension in the neonatal intensive care unit (NICU) is inadequately defined, and the current utilization of antihypertensive medications in this specialized environment is not known. We evaluated the incidence of hypertension, associated risk factors, and utilization of antihypertensive drugs in the NICU using a large, geographically diverse pediatric database. A total of 123,847 NICU encounters were identified in the database. After exclusion of the 44,861 neonates with congenital cardiac disorders, 764 (1%) were coded with the diagnosis of hypertension. On multivariate analysis, the risk for hypertension was greatest in those neonates with a high All Patient Refined Diagnosis Related Groups (APR-DRG) severity of illness assessment (OR = 35.8), extracorporeal membrane oxygenation (OR = 3.8), coexisting renal disorder (OR = 4.7), and renal failure (OR = 2.4). Of the 441 (57.7%) infants receiving antihypertensive medication, the median duration of exposure was 10 days, and 45% were exposed to more than one antihypertensive medication. Vasodilators were used in 64.2% of hypertensive neonates, followed by angiotensin-converting enzyme inhibitors (50.8%), calcium channel blockers (24%), and alpha- and beta-blockers (18.4%). Although hypertension occurs infrequently in the NICU, certain neonates are at increased risk for this condition. Hypertensive infants are frequently exposed to antihypertensive medications, often to several different agents during their NICU course of treatment.