Children's Hospital Association

To evaluate trends in neonatal intensive care unit (NICU) admissions, illness acuity, and hospitalization costs among U.S. children's hospitals from 2017 to 2022. This retrospective cohort study used data from the Pediatric Health Information System (PHIS) and included all NICU admissions. We examined trends in patient characteristics (e.g., gestational age, complex chronic conditions), illness severity scores, and standardized hospital costs. Interrupted time series analyses assessed changes in NICU costs over time. There were 234,571 infants admitted to NICUs in US children's hospitals between 2017 and 2022. NICU admissions shifted significantly by gestational age with admissions increasing by 10-18% among extremely, very, and late preterm infants. Term infants remained the largest admission group, averaging 45% annually (p < 0.001). Infants with ≥1 complex chronic condition increased from 46.6% in 2017 to 50.9% in 2022 (p < 0.001). NICU-specific illness severity increased modestly over time (1.14-1.24, p < 0.001). Median standardized NICU hospital costs rose by approximately 20% over the study period, with notable inflections in early 2020 and 2021. Among US children's hospitals in the PHIS database, NICU admissions were increasingly complex and costly. These findings highlight the importance of ongoing monitoring of resource use and patient mix in specialized NICU settings.

Headache evaluation and treatment are believed to be influenced by race and ethnicity. Specific headache diagnosis assigned in the pediatric emergency department (ED) may compound disparities. We sought to investigate racial and ethnic disparities in the diagnosis, testing, and treatment of pediatric patients with headache presenting to the ED. We performed a cross-sectional analysis of ED visits from 49 children's hospitals between 2016 and 2022 from the Pediatric Health Information System, an administrative database of ED and hospitalized encounters within children's hospitals in the United States. Index encounters in the ED from patients (aged 5-21 years, median age 13 [10-15]) with a primary diagnosis of migraine, headache, new daily persistent headache, or tension-type headache were included. Encounters with trauma, infection, and malignancy where secondary headache was possible were excluded. The primary outcomes were the rates of migraine diagnosis, testing, and treatment. We used generalized estimating equations to estimate associations between race and ethnicity and outcomes after adjusting for demographic factors, medical complexity, visit timing, and final headache diagnosis. A total of 309,678 encounters were included while 61,677 repeat visits, 81,821 visits with diagnoses suggestive of secondary headache, and 5,714 visits from 3 hospitals with sparse data on patient race/ethnicity were excluded. Of 160,466 eligible visits (59.8% female), 41% were by non-Hispanic White (NHW) children, 24.8% non-Hispanic Black (NHB), and 26.0% Hispanic/Latino (HL). NHW children were more frequently diagnosed with migraine (45.5% vs NHB 28.2% and HL 28.3%, p < 0.001). NHB and HL children compared with NHW children received less testing including brain MRI scans (adjusted odds ratio [aOR]: NHB 0.56 [95% CI 0.46-0.69] and HL 0.54 [0.36-0.82]). There was no difference in the proportion of visits without administration of headache-related medications (NHW 23.3% vs NHB 24.6% and HL 23.4%, p = 0.64). NHB and HL children were more likely to receive only oral medications (aOR: NHB 1.37 [1.2-1.56] and HL 1.54 [1.34-1.76]) and less likely to be admitted inpatient (aOR: NHB 0.8 [0.66-0.97] and HL 0.65 [0.44-0.94]). NHB and HL children in the pediatric ED with headache receive fewer migraine diagnoses, less testing, and less intensive treatment compared with NHW children. Beyond affecting headache management, this inequity in migraine diagnosis requires further consideration to include children from marginalized racial and ethnic groups in future migraine research.

BackgroundGiven the most recent report of the nationwide rise of congenital syphilis (CS), with over a 773% increase from 2012 to 2021 per the Center for Disease Control and Prevention, we sought to utilize penicillin administration and ICD-10 billing data as proxies to assess the accuracy of diagnosis of congenital syphilis among major tertiary care pediatric hospitals.MethodsThis retrospective cohort study drawing data from 49 major tertiary children's hospitals in the United States sought to determine whether administration of penicillin in infants 30days or younger, excluding other common infectious diseases treated with the medication, correlated with recently reported congenital syphilis epidemiologic data.Results2290 infants met inclusion criteria and received penicillin therapy, excluding infants with the most common secondary infections treated with penicillin, with 1123 (49.3%) of those included not having a syphilis diagnosis made. Of the neonates with a coded diagnosis of CS, (1107/1162) 95.3% received more than 1day of penicillin therapy, and those not coded for CS that received more than 1day of penicillin therapy was 37.9% (428/1128).ConclusionsOur findings found a significant number of infants who had penicillin administration and laboratory and procedural workup performed suggestive of congenital syphilis consideration, without a congenital syphilis diagnosis billed. This may reflect an underestimation of what is notably a growing nationwide pandemic. By addressing the screening and treatment needs of patients with CS, we can help to address some of the socioeconomic inequities in pediatric and maternal healthcare, and further accurately characterize the extent of this increasingly prevalent disease process.

Introduction/Background: Critical congenital heart disease (CCHD), requiring surgical intervention in the neonatal period, confers significant morbidity including high healthcare utilization, symptom burden, and psychosocial difficulties. Families also face the challenge of numerous decisions surrounding early, high-risk operative and procedural interventions. Pediatric palliative care (PPC) can facilitate goals of care/decision-making conversations and as such has great potential to improve the experiences of and outcomes for children with CCHD and their families. Goals/Aims: We examined the healthcare utilization of children with CCHD and how this differed by sociodemographic and clinical factors, as well as PPC consultation. Methods: We performed a retrospective review of infants with one of five CCHD (anomalous pulmonary venous return [APVC], single ventricle disease [SVD], tetralogy of Fallot [TOF], transposition of the great arteries [TGA], and truncus arteriosus [TA]) enrolled from birth to 2 years old between 2016 and 2020 in Medicaid in 12 U.S states participating in the Merative Marketscan Medicaid. Healthcare utilization included inpatient stays, outpatient and emergency visits, pharmacy encounters, and surgical interventions (SI), and were summed to determine total healthcare days (HD). PPC consultation was also assessed. Multivariable log-normal models assessed patient factors [including complex chronic conditions (CCC)] associated with total HD. Results: The cohort included 615 children (28% non-White, 46% female, and 67% with at least two other CCC) who underwent a median of 8 SI and had 69 HD during the two-year follow up period. SVD patients had the highest utilization and intervention burden (median 117.5 HD, 11.5 SI), followed by TOF (82 HD, 10 SI), TGA (58 HD, 8 SI), APVC (51 HD, 7 SI), and TA (47.5 HD, 3.5 SI) (p&lt;0.001). Having three or more CCC was associated with greater HD for all conditions (p&lt;.001). PPC consultation was uncommon (4.5%), but greatest in SVD (13%) (p&lt;0.001). Conclusions: Children with CCHD, especially those with SVD and greater medical complexity, had significant healthcare utilization including numerous SI. PPC consultation occurs for few patients. Given the clinical and psychosocial implications of frequent decision making and medicalization for children with CCHD, greater PPC engagement should be investigated.

Background: Survivors of infant heart surgery are at greater risk for neurodevelopmental (ND) disorders. Rates of ND diagnoses (dx) and resource utilization are derived from referral centers or single-state studies, with few multi-state data on diagnosis and utilization across inpatient and outpatient settings. Methods: We characterized ND dx, medications, screening/evaluation, and non-medical therapies up to 5 years of life among children born in 2016-2020 in the Merative MarketScan Medicaid Claims database from 12 anonymized states. Surgical complexity was assessed with RACHS-2 category. Cox proportional hazards regression was used to identify risk factors for time to 1) first ND dx and 2) first ND evaluation/intervention. Results/Data: Among 3,147 patients enrolled for a mean 30.5 months, surgery was neonatal in 48%; 23% had a genetic dx; and highest RACHS-2 category was 1= 30%, 2=29%, 3=13%, 4=18%, and 5=10%. Brain imaging was performed in 13%, most commonly MRI (8%). Without adjusting for variable follow-up, the proportion with ≥1 ND dx was 41%, most commonly Communication Disorder (25%), Global Developmental Delay (15%), and Motor Disorder (19%). At latest follow-up, 85% had received ≥1 ND service and 78%, ≥1 direct intervention (ST, OT, and/or PT). Brief ND screening was completed in &gt;58%, but few had psychological/neuropsychological (6.6%) or comprehensive developmental (8.5%) evaluation. Use of stimulants (0.5%), anti-depressants (0.1%) and antipsychotics (0.2%) were uncommon, but anticonvulsants had been used in 7.3%. Independent risk factors for earlier time to any ND dx were Black (p=0.043) or Hispanic (p=0.032) vs. White race/ethnicity, and RACHS-2 Category 4 (p=0.002) or 5 (p=0.007) vs. 1. Independent risk factors for shorter time to first ND evaluation or intervention included RACHS-2 Classes 2 (p=0.012), 4 (p&lt;.001), and 5 (p&lt;.001). Birth sex and genetic abnormalities were not significant predictors of ND dx or utilization. Data for center and region were not available. Conclusions: The prevalence of ND dx and utilization of ND services was high up to age 5 years in this population-based sample of publicly insured children who underwent infant heart surgery. Rates of developmental screening were comparable to those in general pediatric samples, but few children received formal ND evaluations, falling short of AHA recommendations for universal developmental evaluation.

Children with new tracheostomy and invasive mechanical ventilation (IMV) require transitional care involving caregiver education and nursing support. To better understand hospital resource use during this transition, our study aimed to: (1) define and characterize low-resource days (LRDs) for this population and (2) identify factors associated with LRD occurrence. This retrospective cohort analysis included children ≤21 years with new tracheostomy and IMV dependence admitted to an ICU from 2017 to 2022 using the Pediatric Health Information System database. A LRD was defined as a post tracheostomy day that accrued nonroom charges <10% of each patient's accrued nonroom charges on postoperative day 1. Factors associated with LRDs were analyzed using negative binomial regression. Among 4048 children, median post tracheostomy stay was 69 days (interquartile range 34-127.5). LRDs were common: 38.6% and 16.4% experienced ≥1 and ≥7 LRDs, respectively. Younger age at tracheostomy (0-7 days rate ratio [RR] 2.42 [1.67-3.51]; 8-28 days RR 1.8 (1.2-2.69) versus 29-365 days; Asian race (RR 1.5 [1.04-2.16]); early tracheostomy (0-7 days RR 1.56 [1.2-2.04]), and longer post tracheostomy hospitalizations (31-60 days RR 1.85 [1.44-2.36]; 61-90 days RR 2.14 [1.58-2.91]; >90 days RR 2.21 [1.71-2.86]) were associated with more LRDs. Approximately 1 in 6 children experienced ≥7 LRDs. Younger age, early tracheostomy, Asian race, and longer hospital stays were associated with increased risk of LRDs. Understanding the postacute phase, including bed utilization, serves as an archetype to explore care models for children with IMV dependence.