Health outcomes in US children with abdominal pain at major emergency departments associated with race and socioeconomic status.

OBJECTIVE: Over 9.6 million ED visits occur annually for abdominal pain in the US, but little is known about the medical outcomes of these patients based on demographics. We aimed to identify disparities in outcomes among children presenting to the ED with abdominal pain linked to race and SES. METHODS: Data from 4.2 million pediatric encounters of abdominal pain were analyzed from 43 tertiary US children's hospitals, including 2.0 million encounters in the emergency department during 2004-2011. Abdominal pain was categorized as functional or organic abdominal pain. Appendicitis (with and without perforation) was used as a surrogate for abdominal pain requiring emergent care. Multivariate analysis estimated likelihood of hospitalizations, radiologic imaging, ICU admissions, appendicitis, appendicitis with perforation, and time to surgery and hospital discharge. RESULTS: Black and low income children had increased odds of perforated appendicitis (aOR, 1.42, 95% CI, 1.32- 1.53; aOR, 1.20, 95% CI 1.14 - 1.25). Blacks had increased odds of an ICU admission (aOR, 1.92, 95% CI 1.53 - 2.42) and longer lengths of stay (aHR, 0.91, 95% CI 0.86 - 0.96) than Whites. Minorities and low income also had lower rates of imaging for their appendicitis, including CT scans. The combined effect of race and income on perforated appendicitis, hospitalization, and time to surgery was greater than either separately. CONCLUSIONS: Based on race and SES, disparity of health outcomes exists in the acute ED setting among children presenting with abdominal pain, with differences in appendicitis with perforation, length of stay, and time until surgery.

Pediatric Patient and Hospital Characteristics Associated With Treatment of Peritonsillar Abscess and Peritonsillar Cellulitis.

OBJECTIVE: To identify patient and hospital characteristics associated with the choice of treatment for pediatric patients who present in the acute setting with peritonsillar abscess/cellulitis (PTA/PTC). STUDY DESIGN: A retrospective cohort study was performed using Healthcare Cost and Utilization Project emergency department, ambulatory, and inpatient state databases for the years 2010 and 2011. Children aged 0 to 17 years were identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code for PTA/PTC. The main outcome of interest was treatment received, which included medical therapy alone, incision and drainage (IND) or tonsillectomy. Multiple logistic regression analyses were conducted to model non-clinical factors associated with treatment received after adjusting for age, hospital state, race, primary expected payer, existing chronic condition(s), and type of hospital. RESULTS: We identified 2994 patients who presented with PTA/PTC. The most common treatment choice was medical therapy alone (30.8%), followed by IND (30.5%) and tonsillectomy (9.4%). There were significant associations between treatment choice and race, primary payer status, and type of hospital (P < .05). We found that Hispanic patients, those with Medicaid as their primary expected payer, and those treated at a designated children's hospital were 3 nonclinical factors independently associated with an increase in likelihood of receiving tonsillectomy as treatment. CONCLUSION: There are important nonclinical factors associated with treatment of children who present in the acute setting with PTA/PTC. Additional research is recommended to understand these observed differences in care and how they may affect health outcomes.

Characteristics and direct costs of academic pediatric subspecialty outpatient no-show events.

BACKGROUND: Clinic no shows (NS) create a lost opportunity for provider-patient interaction and impose a financial burden to the healthcare system and on society. We aimed to: (1) to determine the clinical and demographic factors associated with increased NS rates at a children's hospital's subsubspecialty clinics and (2) to estimate the direct institutional financial costs associated with NS events. METHODS: A comprehensive database was generated from all clinic encounters for 15 subspecialty outpatient clinics (five surgical and 10 medical) between September 12, 2005 and December 30, 2010. Multivariate logistic regressions were performed to identify the variables associated with NS events. Direct costs of NS events were estimated using annual revenue for each clinic. RESULTS: A total of 284,275 encounters and 17,024 NS events were available for analysis. Public insurance coverage (Medicaid and Title V), compared to private insurance or self-pay status, was associated with an increased likelihood NS (OR 2.19, 95% CI 2.10-2.28, p < 0.0005 for Medicaid; OR 1.56, 95% CI 1.50-1.62, p < 0.0005 for Title V). Compared to patients 21-30 years of age, patients <12 years (OR 2.08, 95% CI 1.77-2.45, p < 0.0005) had increased likelihood of NS. Scheduled visits with medical subspecialists were more likely than surgical subspecialty visits to result in a NS (OR 1.69, 95% CI 1.63-1.75, p < 0.0005). The predicted annualized lost revenue associated with NS visits was estimated at $730,000 from the 15 clinics analyzed, approximately $210 per NS event. CONCLUSION: Pediatric subspecialty NS events are common, costly, and potentially preventable.

Preliminary assessment of pediatric health care quality and patient safety in the United States using readily available administrative data.

OBJECTIVES: With >6 million hospital stays, costing almost $50 billion annually, hospitalized children represent an important population for which most inpatient quality indicators are not applicable. Our aim was to develop indicators using inpatient administrative data to assess aspects of the quality of inpatient pediatric care and access to quality outpatient care. METHODS: We adapted the Agency for Healthcare Research and Quality quality indicators, a publicly available set of measurement tools refined previously by our team, for a pediatric population. We systematically reviewed the literature for evidence regarding coding and construct validity specific to children. We then convened 4 expert panels to review and discuss the evidence and asked them to rate each indicator through a 2-stage modified Delphi process. From the 2000 and 2003 Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project Kids' Inpatient Database, we generated national estimates for provider level indicators and for area level indicators. RESULTS: Panelists recommended 18 indicators for inclusion in the pediatric quality indicator set based on overall usefulness for quality improvement efforts. The indicators included 13 hospital-level indicators, including 11 based on complications, 1 based on mortality, and 1 based on volume, as well as 5 area-level potentially preventable hospitalization indicators. National rates for all 18 of the indicators varied minimally between years. Rates in high-risk strata are notably higher than in the overall groups: in 2003 the decubitus ulcer pediatric quality indicator rate was 3.12 per 1000, whereas patients with limited mobility experienced a rate of 22.83. Trends in rates by age varied across pediatric quality indicators: short-term complications of diabetes increased with age, whereas admissions for gastroenteritis decreased with age. CONCLUSIONS: Tracking potentially preventable complications and hospitalizations has the potential to help prioritize quality improvement efforts at both local and national levels, although additional validation research is needed to confirm the accuracy of coding.

Effect of opening midlevel neonatal intensive care units on the location of low birth weight births in California.

OBJECTIVE: Despite evidence and recommendations encouraging the delivery of high-risk newborns in hospitals with subspecialty or high-level NICUs, increasing numbers are being delivered in other facilities. Causes for this are unknown. We sought to explore the impact of diffusion of specialty or midlevel NICUs on the types of hospitals in which low birth weight newborns are born. DESIGN: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level). RESULTS: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (-15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (-2 points). Similar patterns were observed in 1500- to 2499-g newborns. CONCLUSIONS: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Systematic review: surveillance systems for early detection of bioterrorism-related diseases.

BACKGROUND: Given the threat of bioterrorism and the increasing availability of electronic data for surveillance, surveillance systems for the early detection of illnesses and syndromes potentially related to bioterrorism have proliferated. PURPOSE: To critically evaluate the potential utility of existing surveillance systems for illnesses and syndromes related to bioterrorism. DATA SOURCES: Databases of peer-reviewed articles (for example, MEDLINE for articles published from January 1985 to April 2002) and Web sites of relevant government and nongovernment agencies. STUDY SELECTION: Reports that described or evaluated systems for collecting, analyzing, or presenting surveillance data for bioterrorism-related illnesses or syndromes. DATA EXTRACTION: From each included article, the authors abstracted information about the type of surveillance data collected; method of collection, analysis, and presentation of surveillance data; and outcomes of evaluations of the system. DATA SYNTHESIS: 17,510 article citations and 8088 government and nongovernmental Web sites were reviewed. From these, the authors included 115 systems that collect various surveillance reports, including 9 syndromic surveillance systems, 20 systems collecting bioterrorism detector data, 13 systems collecting influenza-related data, and 23 systems collecting laboratory and antimicrobial resistance data. Only the systems collecting syndromic surveillance data and detection system data were designed, at least in part, for bioterrorism preparedness applications. Syndromic surveillance systems have been deployed for both event-based and continuous bioterrorism surveillance. Few surveillance systems have been comprehensively evaluated. Only 3 systems have had both sensitivity and specificity evaluated. LIMITATIONS: Data from some existing surveillance systems (particularly those developed by the military) may not be publicly available. CONCLUSIONS: Few surveillance systems have been specifically designed for collecting and analyzing data for the early detection of a bioterrorist event. Because current evaluations of surveillance systems for detecting bioterrorism and emerging infections are insufficient to characterize the timeliness or sensitivity and specificity, clinical and public health decision making based on these systems may be compromised.

Perinatal screening for group B streptococci: cost-benefit analysis of rapid polymerase chain reaction.

OBJECTIVE: To evaluate the costs and benefits of a group B streptococci screening strategy using a new, rapid polymerase chain reaction test in a hypothetical cohort of expectant mothers in the United States. DESIGN: Cost-benefit analysis using the human capital method. We developed a decision model to analyze the costs and benefits of a hypothetical group B streptococci screening strategy using a new, rapid polymerase chain reaction test as compared with the currently recommended group B streptococci screening guidelines-prenatal culture performed at 35 to 37 weeks or risk-factor-based strategy with subsequent intrapartum treatment of the expectant mothers with antibiotics to prevent early-onset group B streptococcal infections in their infants. PARTICIPANTS: A hypothetical cohort of pregnant women and their newborns. INTERVENTIONS: Screening strategies for group B streptococci using the new polymerase chain reaction technique, the 35- to 37-week culture, or maternal risk factors. OUTCOME MEASURES: Infant infections averted, infant deaths, infant disabilities, costs, and societal benefits of healthy infants. RESULTS: A screening strategy using the new polymerase chain reaction test generates a net benefit of $7 per birth when compared with the maternal risk-factor strategy. For every 1 million births, 80 700 more women would receive antibiotics, 884 fewer infants would become infected with early-onset group B streptococci, and 23 infants would be saved from death or disability. The polymerase chain reaction-based strategy generates a net benefit of $6 per birth when compared with the 35- to 37-week prenatal culture strategy and results in fewer maternal courses of antibiotics (64 080 per million births), fewer perinatal infections with early-onset group B streptococci (218/million), and a reduction in 6 infant deaths and severe infant disability per million births. The benefits hold over a wide range of assumptions regarding key factors in the analysis. CONCLUSIONS: Although additional clinical trials are needed to establish the accuracy of this new polymerase chain reaction test, initial studies suggest that strategies using this test will be superior to the other 2 strategies. Using the rapid polymerase chain reaction test becomes less attractive as the cost of the test increases. The test's greatest strengths lie in its ability to identify women and infants at risk at the time of labor, thereby decreasing the number of false-positives and false-negatives seen with the other 2 strategies and allowing for more accurate and effective intrapartum prophylaxis.