BACKGROUND Hospitalizations of children with medical complexity (CMC) account for one‐half of hospital days in children, with lengths of stays (LOS) that are typically longer than those for children without medical complexity. The objective was to assess the impact of, risk factors for, and variation across children's hospitals regarding long LOS (≥10 days) hospitalizations in CMC. METHODS A retrospective study of 954,018 CMC hospitalizations, excluding admissions for neonatal and cancer care, during 2013 to 2014 in 44 children's hospitals. CMC were identified using 3M's Clinical Risk Group categories 6, 7, and 9, representing children with multiple and/or catastrophic chronic conditions. Multivariable regression was used to identify demographic and clinical characteristics associated with LOS ≥10 days. Hospital‐level risk‐adjusted rates of long LOS generated from these models were compared using a covariance test of the hospitals' random effect. RESULTS Among CMC, LOS ≥10 days accounted for 14.9% (n = 142,082) of all admissions and 61.8% ($13.7 billion) of hospital costs. The characteristics most strongly associated with LOS ≥10 days were use of intensive care unit (ICU) (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.4‐3.5), respiratory complex chronic condition (OR: 2.7, 95% CI: 2.6‐2.7), and transfer from another medical facility (OR: 2.1, 95% CI: 2.0‐2.1). After adjusting for severity, there was significant (P < 0.001) variation in the prevalence of LOS ≥10 days for CMC across children's hospitals (range, 10.3%–21.8%). CONCLUSIONS Long hospitalizations for CMC are costly. Their prevalence varies significantly by type of chronic condition and across children's hospitals. Efforts to reduce hospital costs in CMC might benefit from a focus on prolonged LOS. Journal of Hospital Medicine 2016;11:750–756. © 2016 Society of Hospital Medicine
To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. METHODS:We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series.RESULTS: Of 111 813 children who underwent tonsillectomy, 54 043 and 57 770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P , .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, 20.02% to 0.29%; P , .001). Antibiotic use decreased from 34.7% to 21.8% (P , .001), as did its rate of change in use (percentage change per month, 20.17% to 20.56%; P , .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P , .001) because of an increase in revisits for pain. Hospital-level results were similar. CONCLUSIONS:The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain. WHAT'S KNOWN ON THIS SUBJECT:Tonsillectomy guidelines make evidence-based recommendations for the perioperative use of dexamethasone, no routine use of antibiotics, and discharge education of families and for surgeons to monitor bleeding complication rates. The impact of the guidelines on processes and outcomes is unknown. WHAT THIS STUDY ADDS:The guidelines were associated with improvement in perioperative care processes but no improvement in outcomes. Perioperative dexamethasone use increased slightly, and antibiotic use decreased substantially. Bleeding rates were stable, but revisit rates for complications increased because of revisits for pain.
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