IMPORTANCE A high cesarean delivery rate in US hospitals indicates the potential overuse of this procedure; however, underlying causes of the excessive use of cesarean procedures in the US have not been fully understood. OBJECTIVE To investigate the association between the probability of cesarean delivery at the patient-level and profit per procedure from cesarean deliveries. DESIGN, SETTING, AND PARTICIPANTS This observational, cross-sectional study used a nationally representative sample of hospital discharge data from women at low risk for cesarean birth who delivered newborns between 2010 and 2014 in the US. Data were gathered from the Nationwide Readmissions Database from the Healthcare Cost and Utilization Project, compiled by the Agency for Healthcare Research and Quality. Data cleaning and analyses were conducted between August 2019 and May 2020. EXPOSURES Hospital-level median value of profits from cesarean deliveries, defined as the difference between the charge and the cost for cesarean delivery calculated for each hospital. MAIN OUTCOMES AND MEASURES Our primary outcome was the individual-level probability of undergoing a cesarean delivery. We examined the association with the hospital-level median value of profits per procedure for cesarean delivery (defined as the difference between the charge and the cost for cesarean delivery) using hierarchical regression models adjusted for patient and hospital characteristics and year-fixed effects. RESULTS A total of 13 215 853 deliveries were included in our analyses (mean [SE] age, 27.4 [0] years), of which 2 202 632 (16.7%) were cesarean deliveries. After adjusting for potential confounders, pregnant women were more likely to have a cesarean birth when they delivered at hospitals with higher profits per procedure from cesarean deliveries. Women cared for at hospitals with the highest (adjusted odds ratio, 1.08; 95% CI, 1.02-1.14; P = .005) and second-highest profit quartiles (adjusted odds ratio, 1.07; 95% CI, 1.02-1.13; P = .007) had higher probabilities of a cesarean delivery compared with those cared for at hospitals in the lowest profit quartile. CONCLUSIONS AND RELEVANCE In this cross-sectional study of US nationally representative hospital discharge data, hospitals with higher profits per cesarean procedure were associated with an increased probability of delivering newborns through cesarean birth. These findings highlight the potential influence financial incentives play in determining a high cesarean delivery rate in the US.

Objective Regionalization directs patients to high‐volume hospitals for specialized care. We investigated regionalization trends and outcomes in pediatric cardiac surgery. Data Sources/Study Setting Statewide inpatient data from eleven states between 2000 and 2012. Study Design Mortality, length of stay (LOS), and cost were assessed using multivariable hierarchical regression with state and year fixed effects. Primary predictor was hospital case‐volume, categorized into low‐, medium‐, and high‐volume tertiles. Data Collection/Extraction Methods We used Risk Adjustment for Congenital Heart Surgery‐1 (RACHS‐1) to select pediatric cardiac surgery discharges. Principal Findings In total, 2841 (8.5 percent), 8348 (25.1 percent), and 22 099 (66.4 percent) patients underwent heart surgeries in low‐, medium‐, and high‐volume hospitals. Mortality decreased over time, but remained higher in low‐ and medium‐volume hospitals. High‐volume hospitals had lower odds of mortality and cost than low‐volume hospitals (odds ratio [OR] 0.59, P < 0.01, and relative risk [RR] 0.91, P < 0.01, respectively). LOS was longer for high‐ and medium‐volume hospitals, compared to low‐volume hospitals (high‐volume: RR 1.18, P < 0.01; medium‐volume: RR 1.05, P < 0.01). Conclusions Regionalization reduced mortality and cost, indicating fewer complications, but paradoxically increased LOS. Further research is needed to explore the full impact on health care utilization.

BACKGROUND AND OBJECTIVES: Asthma is widely prevalent among US children, particularly in homeless children, who often lack proper medication storage or the ability to avoid environmental triggers. In this study, we assess asthma-attributed health care use among homeless youth. We hypothesize that asthma hospitalization rates, symptom severity, and admission through the emergency department (ED) will be higher among homeless youth compared with nonhomeless youth. METHODS: This secondary data analysis identified homeless and nonhomeless pediatric patients (,18 years old) with a primary diagnosis of asthma from New York statewide inpatient databases between 2009 and 2014. Hospitalization rate, readmission rate, admission through the ED, ventilation use, ICU admittance, hospitalization cost, and length of stay were measured. RESULTS: We identified 71 837 asthma hospitalizations, yielding 73.8 and 2.3 hospitalizations per 1000 homeless and nonhomeless children, respectively. Hospitalization rates varied by nonhomeless income quartile, with low-income children experiencing higher rates (5.4) of hospitalization. Readmissions accounted for 16.0% of homeless and 12.5% of nonhomeless hospitalizations. Compared with nonhomeless patients, homeless patients were more likely to be admitted from the ED (odds ratio 1.96; 95% confidence interval: 1.82-2.12; P , .01), and among patients .5 years old, homeless patients were more likely to receive ventilation (odds ratio 1.45; 95% confidence interval: 1.01-2.09; P 5 .04). No significant differences were observed in ICU admittance, cost, or length of stay. CONCLUSIONS: Homeless youth experience an asthma hospitalization rate 31 times higher than nonhomeless youth, with higher rates of readmission. Homeless youth live under uniquely challenging circumstances. Tailored asthma control strategies and educational intervention could greatly reduce hospitalizations. WHAT'S KNOWN ON THIS SUBJECT: Asthma is widely prevalent among US children, particularly in homeless children, who often lack proper medication storage or ability to avoid environmental triggers. Poor treatment adherence and follow-up have been reported, making homeless children susceptible to attacks. WHAT THIS STUDY ADDS: Because of high prevalence and attack susceptibility, use of health care by homeless patients with asthma could be high. However, no prior studies have quantified these levels. This study offers new insight on asthma-attributed health care use among homeless and nonhomeless youth.

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ObjectiveTo assess differences in rates of postpartum hospitalisations among homeless women compared with non-homeless women.DesignCross-sectional secondary analysis of readmissions and emergency department (ED) utilisation among postpartum women using hierarchical regression models adjusted for age, race/ethnicity, insurance type during delivery, delivery length of stay, maternal comorbidity index score, other pregnancy complications, neonatal complications, caesarean delivery, year fixed effect and a birth hospital random effect.SettingNew York statewide inpatient and emergency department databases (2009–2014).Participants82 820 and 1 026 965 postpartum homeless and non-homeless women, respectively.Main outcome measuresPostpartum readmissions (primary outcome) and postpartum ED visits (secondary outcome) within 6 weeks after discharge date from delivery hospitalisation.ResultsHomeless women had lower rates of both postpartum readmissions (risk-adjusted rates: 1.4% vs 1.6%; adjusted OR (aOR) 0.87, 95% CI 0.75 to 1.00, p=0.048) and ED visits than non-homeless women (risk-adjusted rates: 8.1% vs 9.5%; aOR 0.83, 95% CI 0.77 to 0.90, p<0.001). A sensitivity analysis stratifying the non-homeless population by income quartile revealed significantly lower hospitalisation rates of homeless women compared with housed women in the lowest income quartile. These results were surprising due to the trend of postpartum hospitalisation rates increasing as income levels decreased.ConclusionsTwo factors likely led to lower rates of hospital readmissions among homeless women. First, barriers including lack of transportation, payment or childcare could have impeded access to postpartum inpatient and emergency care. Second, given New York State’s extensive safety net, discharge planning such as respite and sober living housing may have provided access to outpatient care and quality of life, preventing adverse health events. Additional research using outpatient data and patient perspectives is needed to recognise how the factors affect postpartum health among homeless women. These findings could aid in lowering readmissions of the housed postpartum population.

The purpose of the study is to examine (1) nationally representative incidence rates of Emergency Department (ED) visits due to sudden cardiac arrest (SCA) in pediatric and young adult populations, (2) basic characteristics of the ED visits with SCA, and (3) patient and hospital factors associated with survival after SCA. We used the Nationwide Emergency Department Sample from 2006 to 2013. ICD-9-CM diagnostic codes identified ED visits due to SCA for patients ≤ 30 years old. Outcomes included yearly incidence of ED visits for SCA, and survival to hospital discharge. Predictors of interest were age groups, sex, and SCA case volume. A logistic regression model adjusted by patient- and hospital-level variables was used. Stratified analyses of age by (< 12 and ≥ 12 years old) were performed to explore the effect of pubertal development on SCA. With 71,881 ED visits due to SCA, the total incidence rate was 6.9 per 100,000 population, with a mortality rate of 89.6% and male/female ratio of 1.7. With the adjusted regression models, there were no differences in survival rate by sex; however, when stratified at 12 years old, males were less likely to survive than females above 12 years old (odds ratio [OR] 0.71, P < 0.01), but not under 12 years old. No statistically significant differences in survival rates between low- and high-SCA volume EDs were detected (OR 1.03, P = 0.77). Data showed no benefit of regionalized care for post-SCA in ≤ 30-year-old populations. With further examination of the differences between sexes, new management strategies for SCA cases can be developed.

Background: An easy-to-operate ECG recorder should be useful for newborn screening for heart conditions, by health care workers --or parents. We developed a one-piece electrode strip and a compact, 12-lead ECG recorder for newborns. Method:We enrolled 2,582 newborns in a trial to assess abilities of parents to record a 12-lead ECG on their infants (2-4 weeks-old). Newborns were randomized to recordings by parents (1,290) or our staff (1,292 controls). Educational backgrounds of parents varied, including 64% with no more than a high school diploma.Results: For newborns randomized to parent recorded ECGs, 94% of parents completed a 10minute recording. However, 42.6% asked for verbal help, and 12.7% needed physical help.ECG quality was the same for recordings by parents versus staff. Conclusions:By use of a one-piece electrode strip and a compact recorder, 87% of parents recorded diagnostic quality ECGs on their newborn infants, with minimal assistance.

This study investigated patient characteristics in paediatric hospitalisations for hypertrophic cardiomyopathy. We used Nationwide Inpatient Sample, which is the largest all-payer inpatient database in the United States, yielding nationally representative estimates, from 2001 to 2014. ICD-9-CM diagnostic codes identified hospitalisations for patients with hypertrophic cardiomyopathy and <18 years. Outcomes included yearly rate of hospitalisation, death, admission via emergency department, and need for surgery. Predictors of interest were age groups (<1, 1–9, and ⩾10 y/o), sex, and race/ethnicity. Logistic regression modelled associations, adjusted by patient- and hospital-level variables. With 2302 weighted hospitalisations, hospitalisation rates were 0.22 per 100,000 children/year, with higher rates for <1 y/o (0.42) and ⩾10 y/o (0.31). Male-to-female ratios were more prominent in the oldest age group; 2.7:1 in ⩾10 y/o versus less than 1.7:1 for <10 y/o. In-hospital mortality was 1.5%, with highest mortality rates among the <1 y/o (6.3%). Children ⩾10 y/o had 5.59 times higher risk of admission from the emergency department than 1–9 y/o age group. Both ⩾10 and <1 y/o age groups had lower risk of surgical intervention compared to the 1–9 y/o group with odds ratio 0.56 and 0.26, respectively. Black children had higher risk of admission from the emergency department than White children with odds ratio 2.78. A relation between age group and sex was observed, with sex-based differences in prevalence and treatment of hypertrophic cardiomyopathy becoming more pronounced with age. Further studies are needed to clarify mechanisms behind age and racial disparity in hospitalisation, especially admission source.