Alison R. Carroll

Background: Outcome disparities exist among children with asthma, though associations between neighborhood conditions and timing and intensity (i.e., emergency department and readmissions) of recurrent hospital‐based reutilization are not well defined. Objective: To evaluate associations between Childhood Opportunity Index (COI) and the intensity and timing of hospital‐based reutilization for asthma. Methods: We studied children (2–17 years) from 47 US children's hospitals with an index admission for asthma from 2021 to 2022 using the Pediatric Health Information System database. The exposure was ZIP code‐level COI 3.0 quintiles (very low to very high). The primary outcome was reutilization intensity (no reutilization, ≥1 emergency department revisit, 1 hospital readmission, and ≥2 hospital readmissions) across four time windows (30, 90, 180, and 365 days), evaluated using ordinal regression. Secondary analyses evaluated time to any reutilization using adjusted restricted mean survival time. Models were adjusted for patient demographics, complexity, distance‐to‐hospital, and severity of index admission. Results: We identified 45,520 index admissions. At 90, 180, and 365 days, lower neighborhood opportunity was associated with higher reutilization intensity; differences widened over successive reutilization windows. Adjusted odds ratios for reutilization intensity in the lowest versus highest COI quintiles were 1.52 (1.36–1.70) at 90 days and 1.89 (1.74–2.06) at 365 days. The adjusted mean time to reutilization was 16 days shorter for the lowest versus highest COI quintile. Conclusions: Lower COI predicted earlier and more intense asthma‐related hospital reutilization. The COI could help identify children with asthma who would benefit most from targeted interventions during a hospital‐based visit to reduce future reutilization.

Pediatric readmissions are important for hospitals to measure and monitor to identify potential improvement opportunities but require benchmarks to contextualize observed and expected readmissions. We developed and validated the Pediatric Readmissions Encounter Predictor (PREP) in administrative data as pediatric readmission benchmarks using the All‐Patient Refined Diagnosis‐Related Groups with severity of illness subclasses. We developed the model using data from the National Readmission Database in 2019. We subsequently validated these models in the same data set from 2018. The overall 30‐day unplanned readmission rate was 2.5%. The model demonstrated acceptable discriminatory performance (area under the receiver operator characteristic curve [AUC] = 0.738, 95% confidence interval [CI]: 0.734, 0.741) and was well calibrated across all levels of predicted probabilities. PREP is a promising readmission prediction model which hospitals can use to assist in identifying improvement opportunities.

Importance: Accurate identification of hospital readmission risk during a current hospitalization may enhance decision-making, facilitate targeted systems-level interventions, and avoid preventable readmissions.Objective: To temporally and externally validate a suite of readmission risk prediction models across 48 children’s hospitals to assess their generalizability and feasibility for future clinical implementation.Design, Setting, and Participants: This prognostic study analyzed data from the Pediatric Health Information System (PHIS) database, which contains billing and resource use data from 48 US children’s hospitals, including the derivation hospital (DH) and 47 hospitals participating in the PHIS database (hereafter other PHIS hospitals). Children aged 18 years or younger discharged from these hospitals between January 1, 2016, to December 31, 2019, were included. This cohort was divided as specified into the 3 prediction models at the DH: 6 months or older with no recent hospitalizations (new admission model [NAM]), 6 months or older with 1 or more prior hospitalizations within the last 6 months (recent admission model [RAM]), and 6 months or younger (young infant model [YIM]). Data were analyzed from August 9 to December 1, 2023.Main Outcomes and Measures: The primary validation outcome was hospital-level discrimination measured with area under the receiver operating characteristic curve (AUROC). Predictors included demographic, clinical, and utilization variables. All-cause 30-day readmission was modeled for each hospital using logistic regression and parameter estimates from the DH. Calibration plots examined observed vs predicted outcome frequencies for each hospital.Results: In external validation, a total of 851 499 children were discharged from 48 hospitals (16 330 DH discharges and 835 169 other PHIS hospital discharges). The largest group of children was aged 5 to 14 years (281 193 [33.0%]). In temporal validation, the DH PHIS 2016-2018 cohort included 45 682 discharges. All-cause 30-day readmission rates were 7.2% for NAM, 35.5% for RAM, and 11.7% for YIM. The 2019 DH PHIS cohort included 16 330 discharges. All cause 30-day readmision rates were 7.2% for NAM, 35.1% for RAM, and 11.1% for YIM. Temporal validation demonstrated reduced discrimination across all 3 models (median AUROC, 0.65 [95% CI 0.62-0.67] for the NAM; 0.73 [95% CI 0.72-0.75) for RAM; 0.67 [95% CI 0.63-0.70) for the YIM compared with the original estimates (median AUROC 0.76 [95% CI 0.85-0.78] for the NAM; 0.84 [95% CI 0.83-0.84] for the RAM; 0.79 [95% CI 0.77-0.80] for the YIM). Overall readmission rates were 5.9% for NAM, 30.1% for RAM, and 7.6% for YIM. External validation yielded similiar findings as the temporal validation, although with demonstrable variation in performance across hospitals (median [range] AUROC, 0.64 [0.60-0.68] for the NAM; 0.73 [0.64-0.80] for the RAM; 0.65 [0.53-0.74] for the YIM). Most hospitals were poorly calibrated, with both significant overestimation and underestimation of observed risk. Of 47 other PHIS hospitals, only 3 for the RAM (6.4%) and 9 for both the NAM and YIM (19.1%) were adequately calibrated.Conclusions and Relevance: This prognostic study found that the readmission risk prediction models had reduced predictive accuracy across time and variability in hospital-level performance. These findings stress the importance of local validation prior to clinical implementation and suggest opportunities to improve generalizability, including multicenter derivation and expansion of candidate predictors.

Background: Children with high‐intensity neurologic impairment (HINI) have an increased risk of urinary tract infection (UTI) and prolonged intravenous (IV) antibiotic exposure.Objective: To determine the association between short (≤3 days) and long (>3 days) IV antibiotic courses and UTI treatment failure in hospitalized children with HINI.Methods: We performed a retrospective cohort study examining UTI hospitalizations at 49 hospitals in the Pediatric Health Information System from 2016 to 2021 for children (1–18 years) with HINI. The primary outcome was UTI readmission within 30 days. Our secondary outcome was the association of hospital‐level variation in short IV antibiotic course use with readmission. Readmission rates were compared between short and long courses using multivariable regression.Results: Of 5612 hospitalizations, 3840 (68.4%) had short IV antibiotic courses. In our adjusted model, children with short IV courses were less likely than with long courses to have a 30‐day UTI readmission (4.0%, 95% CI [3.6%, 4.5%] vs. 6.3%, 95% CI [5.1%, 7.8%]). Despite marked hospital‐level variation in short IV course use (50.0%–87.5% of hospitalizations), there was no correlation with readmissions.Conclusions: Children with HINI hospitalized with UTI had low UTI readmission rates, but those who received long IV antibiotic courses were more likely to experience UTI readmission versus those receiving short courses. While residual confounding may influence our results, we did not find that short IV courses impacted readmission at the hospital level despite variation in use across institutions. Long IV antibiotic courses are associated with risks and may not confer benefit in this population.

Importance: Inadequate communication between caregivers and clinicians at hospital discharge contributes to medication dosing errors in children. Health literacy–informed communication strategies during medication counseling can reduce dosing errors but have not been tested in the pediatric hospital setting.Objective: To test a health literacy–informed communication intervention to decrease liquid medication dosing errors compared with standard counseling in hospitalized children.Design, Setting, and Participants: This parallel, randomized clinical trial was performed from June 22, 2021, to August 20, 2022, at a tertiary care, US children’s hospital. English- and Spanish-speaking caregivers of hospitalized children 6 years or younger prescribed a new, scheduled liquid medication at discharge were included in the analysis.Interventions: Permuted block (n = 4) randomization (1:1) to a health literacy–informed discharge medication communication bundle (n = 99) compared with standard counseling (n = 99). A study team member delivered the intervention consisting of a written, pictogram-based medication instruction sheet, teach back (caregivers state information taught), and demonstration of dosing with show back (caregivers show how they would draw the liquid medication in the syringe).Main Outcome and Measures: Observed dosing errors, assessed using a caregiver-submitted photograph of their child’s medication-filled syringe and expressed as the percentage difference from the prescribed dose. Secondary outcomes included caregiver-reported medication knowledge. Outcome measurements were blinded to participant group assignment.Results: Among 198 caregivers randomized (mean [SD] age, 31.4 [6.5] years; 186 women [93.9%]; 36 [18.2%] Hispanic or Latino and 158 [79.8%] White), the primary outcome was available for 151 (76.3%). The observed mean (SD) percentage dosing error was 1.0% (2.2 percentage points) among the intervention group and 3.3% (5.1 percentage points) among the standard counseling group (absolute difference, 2.3 [95% CI, 1.0-3.6] percentage points; P < .001). Twenty-four of 79 caregivers in the intervention group (30.4%) measured an incorrect dose compared with 39 of 72 (54.2%) in the standard counseling group (P = .003). The intervention enhanced caregiver-reported medication knowledge compared with the standard counseling group for medication dose (71 of 76 [93.4%] vs 55 of 69 [79.7%]; P = .03), duration of administration (65 of 76 [85.5%] vs 49 of 69 [71.0%]; P = .04), and correct reporting of 2 or more medication adverse effects (60 of 76 [78.9%] vs 13 of 69 [18.8%]; P < .001). There were no differences in knowledge of medication name, indication, frequency, or storage.Conclusions and Relevance: A health literacy–informed discharge medication communication bundle reduced home liquid medication administration errors and enhanced caregiver medication knowledge compared with standard counseling. Routine use of these standardized strategies can promote patient safety following hospital discharge.Trial Registration: ClinicalTrials.gov Identifier: NCT05143047

Video Abstract Video Abstract Children hospitalized with a mental health crisis often receive pharmacologic restraint for management of acute agitation. We examined associations between pharmacologic restraint use and race and ethnicity among children admitted for mental health conditions to acute care nonpsychiatric children’s hospitals. We performed a retrospective cohort study of children (aged 5–≤18 years) admitted for a primary mental health condition from 2018 to 2022 at 41 US children’s hospitals. Pharmacologic restraint use was defined as parenteral administration of medications for acute agitation. The association of race and ethnicity and pharmacologic restraint was assessed using generalized linear multivariable mixed models adjusted for clinical and demographic factors. Stratified analyses were performed based on significant interaction analyses between covariates and race and ethnicity. The cohort included 61 503 hospitalizations. Compared with non-Hispanic Black children, children of non-Hispanic White (adjusted odds ratio [aOR], 0.81; 95% confidence interval [CI], 0.72–0.92), Asian (aOR, 0.82; 95% CI, 0.68–0.99), or other race and ethnicity (aOR, 0.68; 95% CI, 0.57–0.82) were less likely to receive pharmacologic restraint. There was no significant difference with Hispanic children. When stratified by sex, racial/ethnic differences were magnified in males (aORs, 0.49–0.68), except for Hispanic males, and not found in females (aORs, 0.83–0.93). Sensitivity analysis revealed amplified disparities for all racial/ethnic groups, including Hispanic youth (aOR, 0.65; 95% CI, 0.47–0.91). Non-Hispanic Black children were significantly more likely to receive pharmacologic restraint. More research is needed to understand reasons for these disparities, which may be secondary to implicit bias and systemic and interpersonal racism.

We examined associations between a validated, multidimensional measure of social determinants of health and population‐based hospitalization rates among children p < .001 for each), from 26.56 per 1000 (95% confidence interval [CI] 26.41–26.71) in very low COI areas to 14.76 per 1000 (95% CI 14.66–14.87) in very high COI areas (incidence rate ratio 1.8; 95% CI 1.78–1.81). Decreasing neighborhood opportunity was associated with increasing hospitalization rates among children in 18 US states. These data underscore the importance of social context and community‐engaged solutions for health systems aiming to eliminate care inequities.

OBJECTIVES: Children are at increased risk for medication errors and the transition from hospital-to-home is a vulnerable time for errors to occur. This study aimed to explore the perspectives of multidisciplinary clinicians and caregivers regarding discharge medication counseling and to develop a conceptual model to inform intervention efforts to reduce discharge medication dosing errors. METHODS: We conducted semistructured interviews with clinicians and caregivers of children <4 years old discharged from the hospital on a liquid medication. A hierarchical coding system was developed using the interview guide and several transcripts. Qualitative analysis employed an iterative inductive-deductive approach to identify domains and subthemes and inform a conceptual framework. RESULTS: We conducted focus groups and individual interviews with 17 caregivers and 16 clinicians. Using the Donabedian structure-process-outcomes model of quality evaluation, domains and subthemes included: (1) infrastructure of healthcare delivery, including supplies for counseling, content and organization of discharge instructions, clinician training and education, roles and responsibilities of team members, and hospital pharmacy delivery and counseling program; (2) processes of healthcare delivery, including medication reconciliation, counseling content, counseling techniques, and language barriers and health literacy; and (3) measurable outcomes, including medication dosing accuracy and caregiver understanding and adherence to discharge instructions. CONCLUSIONS: The conceptual model resulting from this analysis can be applied to the development and evaluation of interventions to reduce discharge medication dosing errors following a hospitalization. Interventions should use a health literacy universal precautions approach—written materials with plain language and pictures and verbal counseling with teach-back and show-back.

Background: Children in mental health crises are increasingly admitted to children's hospitals awaiting inpatient psychiatric placement. During hospitalization, patients may exhibit acute agitation prompting pharmacologic restraint use.Objective: To determine hospital‐level incidence and variation of pharmacologic restraint use among children admitted for mental health conditions in children's hospitals.Design, Setting, and Participants: We examined data for children (5 to ≤18 years) admitted to children's hospitals with a primary mental health condition from 2018 to 2020 using the Pediatric Health Information System database. Hospital rates of parenteral pharmacologic restraint use per 1000 mental health bed days were determined and compared after adjusting for patient‐level and demographic factors. Cluster analysis (k‐means) was used to group hospitals based on overall restraint use (rate quartiles) and drug class. Hospital‐level factors for pharmacologic restraint use were compared.Results: Of 29,834 included encounters, 3747 (12.6%) had pharmacologic restraint use. Adjusted hospital rates ranged from 35 to 389 pharmacologic restraint use days per 1000 mental health bed days with a mean of 175 (standard deviation: 72). Cluster analysis revealed three hospitals were high utilizers of all drug classes. No significant differences in pharmacologic restraint use were found in the hospital‐level analysis.Conclusions: Children's hospitals demonstrate wide variation in pharmacologic restraint rates for mental health hospitalizations, with a 10‐fold difference in adjusted rates between highest and lowest utilizers, and high overall utilizers order medications across all drug classes.

Successful publication of quality improvement (QI) work is predicated on the use of established QI frameworks and rigorous analytical methods that allow teams to understand the impact of interventions over time. This article is meant to help QI teams disseminate their work more broadly through publication by providing tangible methods that many journals desire in QI articles with specific examples of published works referenced throughout the article. We introduce improvement frameworks that teams should identify early and use as a foundation throughout their projects. We review vital aspects of QI projects, such as team formation, creation of a succinct and clear aim statement, defining primary, process, and balancing measures, as well as QI tools like key driver diagrams, Ishikawa (fishbone) diagrams, and Pareto charts. Finally, we highlight the importance of analyzing data over time to understand the impacts of plan-do-study-act cycles on data. Annotated run charts or, more preferably, annotated statistical process control (or Shewhart) charts are both statistically sound methods to identify significant changes over time. Deliberate planning and execution of QI projects using these concepts will lead to improved chances of QI teams finding success in their project and eventual article acceptance.