Characteristics of deaths occurring in hospitalised children: changing trends.
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BACKGROUND: Despite a gradual shift in the focus of medical care among terminally ill patients to a palliative model, studies suggest that many children with life-limiting chronic illnesses continue to die in hospital after prolonged periods of inpatient admission and mechanical ventilation. OBJECTIVES: To (1) examine the characteristics and location of death among hospitalised children, (2) investigate yearwise trends in these characteristics and (3) test the hypothesis that professional ethical guidance from the UK Royal College of Paediatrics and Child Health (1997) would lead to significant changes in the characteristics of death among hospitalised children. METHODS: Routine administrative data from one large tertiary-level UK children's hospital was examined over a 7-year period (1997-2004) for children aged 0-18 years. Demographic details, location of deaths, source of admission (within hospital vs external), length of stay and final diagnoses (International Classification of Diseases-10 codes) were studied. Statistical significance was tested by the Kruskal-Wallis analysis of ranks and median test (non-parametric variables), chi(2) test (proportions) and Cochran-Armitage test (linear trends). RESULTS: Of the 1127 deaths occurring in hospital over the 7-year period, the majority (57.7%) were among infants. The main diagnoses at death included congenital malformations (22.2%), perinatal diseases (18.1%), cardiovascular disorders (14.9%) and neoplasms (12.4%). Most deaths occurred in an intensive care unit (ICU) environment (85.7%), with a significant increase over the years (80.1% in 1997 to 90.6% in 2004). There was a clear increase in the proportion of admissions from in-hospital among the ICU cohort (14.8% in 1998 to 24.8% in 2004). Infants with congenital malformations and perinatal conditions were more likely to die in an ICU (OR 2.42, 95% CI 1.65 to 3.55), and older children with malignancy outside the ICU (OR 6.5, 95% CI 4.4 to 9.6). Children stayed for a median of 13 days (interquartile range 4.0-23.25 days) on a hospital ward before being admitted to an ICU where they died. CONCLUSIONS: A greater proportion of hospitalised children are dying in an ICU environment. Our experience indicates that professional ethical guidance by itself may be inadequate in reversing the trends observed in this study. (+info)
Molecular analysis of the NSP4 and VP6 genes of rotavirus strains recovered from hospitalized children in Rio de Janeiro, Brazil.
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Group A rotaviruses are the main cause of acute gastroenteritis in children throughout the world. The two outer capsid proteins, VP4 and VP7, define the P and G genotypes, respectively. Rotaviruses with P[8]G1, P[4]G2, P[8]G3 and P[8]G4 genotypes are predominant in infecting humans and the G9 genotype is emerging in most continents as the fifth most common G type worldwide. The inner capsid protein VP6 is responsible for subgroup (SG) specificities, allowing classification of rotaviruses into SG I, SG II, SG I+II and SG non-I-non-II. The non-structural protein 4 (NSP4) encoded by segment 10 has a role in viral morphogenesis and five genetic groups have been described, NSP4 genotypes A-E. The aim of this investigation was to characterize the NSP4 and VP6 genes of rotavirus strains recovered from hospitalized children. Thirty rotavirus strains were submitted to RT-PCR followed by sequencing and phylogenetic analysis. Among the different G and P genotype combinations, two distinct genetic groups could be recognized for the NSP4 gene. Twenty-eight clustered with NSP4 genotype B. The two P[4]G2 strains fell into NSP4 genotype A and clustered distinctly, with a 100 % bootstrap value. The strains distinguished within a group were closely related to each other at the nucleotide and amino acid levels. A phylogenetic tree was constructed for the VP6 gene including the human strains RMC100, E210, Wa, US1205 and 1076, and the animal strains Gott, NCDV, SA-11, FI-14 and EW. This is the first report on Brazilian rotavirus strains describing NSP4 genotype A strains associated with VP6 SG I, and NSP4 genotype B strains associated with VP6 SG II. (+info)
Post-neonatal hospitalization and health care costs among IVF children: a 7-year follow-up study.
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BACKGROUND: The objective of this study was to evaluate whether the post-neonatal hospitalization and resulting health care costs are increased among in vitro fertilization (IVF) children up to 7 years of age. METHODS: We conducted a population-based cohort study with linkage to a national hospital discharge register including 303 IVF children, born from 1990 to 1995, and 567 control children (1:2) randomly chosen from the Finnish Medical Birth Register and matched for sex, year of birth, area of residence, parity, maternal age and socioeconomic status. The cost calculations were stratified for singleton (n = 152 vs. n = 285) and twin (n = 103 vs. n = 103) status. Main outcome measures were hospitalizations and societal health care costs. RESULTS: The full-sample and singleton analyses showed that IVF children were significantly more frequently admitted to hospital (mean 1.76 vs. 1.07, P < 0.0001; 1.61 vs. 1.07, P = 0.0004, respectively) and spent significantly more days in the hospital (mean 4.31 vs. 2.61, P < 0.0001; 3.47 vs. 2.56, P = 0.0014, respectively) than control children. No differences were detected between IVF and control twins. The costs of post-neonatal hospital care per child were 2.6-fold for IVF singletons, but 0.7-fold for IVF twins when compared with controls. Cost estimation showed 2.6-fold costs for total IVF population in comparison to general population based controls. CONCLUSIONS: The incidence of multiple births increases the utilization of post-neonatal health care services and costs among IVF children in comparison to naturally conceived children. Increased hospitalization and costs were also seen among IVF singletons. (+info)
Medicaid markets and pediatric patient safety in hospitals.
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OBJECTIVE: To examine the association of Medicaid market characteristics to potentially preventable adverse medical events for hospitalized children, controlling for patient- and hospital-level factors. DATA SOURCES/STUDY SETTING: Two carefully selected Agency for Healthcare Research and Quality (AHRQ) pediatric patient safety indicators (decubitus ulcers and laceration) are analyzed using the new pediatric-specific, risk-adjusting, patient safety algorithm from the AHRQ. All pediatric hospital discharges for patients age 0-17 in Florida, New York, and Wisconsin, and at risk of any of these two patient safety events, are examined for the years 1999-2001 (N=859,922). STUDY DESIGN: Logistic regression on the relevant pool of discharges estimates the probability an individual patient experiences one of the two PSI events. DATA EXTRACTION METHODS: Pediatric discharges from the 1999 to 2001 State Inpatient Databases (SIDs) from the AHRQ Healthcare Cost and Utilization Project, merged with hospital-level data from the American Hospital Association's Annual Survey, Medicaid data obtained from the Centers for Medicare and Medicaid Services and state Medicaid offices, and private and Medicaid managed care enrollment data obtained from InterStudy, are used in the estimations. PRINCIPAL FINDINGS: At the market level, patients in markets in which Medicaid payers face relatively little competition are more likely to experience a patient safety event (odds ratio [OR]=1.602), while patients in markets in which hospitals face relatively little competition are less likely to experience an adverse event (OR=0.686). At the patient-discharge and hospital levels, Medicaid characteristics are not significantly associated with the incidence of a pediatric patient safety event. CONCLUSIONS: Our analysis offers additional insights to previous work and suggests a new factor--the Medicaid-payer market--as relevant to the issue of pediatric patient safety. (+info)
Practices and provisions for parents sleeping overnight with a hospitalized child.
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OBJECTIVE: To describe practices affecting parents' overnight stays, provisions for parents sleeping overnight and parents' involvement in overnight care of their hospitalized child. METHODS: A cross-sectional telephone survey of Canadian and American hospitals with more or equal to 50 acute pediatric beds and more or equal to two pediatric wards was conducted. RESULTS: Surveys were completed by 135 hospitals (77% response rate). All general pediatric units allowed parents to sleep at the bedside overnight; higher acuity units limited parental stays. The majority of hospitals limited overnight visitors at the bedside to one parent, and few hospitals routinely allowed siblings to sleep overnight. One hundred and thirty-three (99%) hospitals reported parental involvement in their child's care at night, with 52 (39%) stating this was an expectation. CONCLUSIONS: In general, parents are given the opportunity to stay at the bedside overnight, but barriers exist that limit opportunities for sleep during their child's hospitalization, and serve to separate families who have a hospitalized child. (+info)
Pediatric hospitalizations for bicycle-related injuries.
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OBJECTIVES: To determine the incidence of bicycle-related injury hospitalizations among children and adolescents 20 years of age and younger and to examine the associated use of healthcare resources. DESIGN: Nationally representative data from the 2003 Healthcare Cost and Utilization Project's Kids' Inpatient Database (KID). OUTCOME MEASURES: National estimates of hospitalization for bicycle-related injuries according to patient demographics, type of injury, total hospital charges, and length of hospital stay. RESULTS: In 2003, an estimated 10,700 children were hospitalized for a bicycle-related injury in the USA. Inpatient charges totaled nearly $200 million with a mean charge of $18,654 per hospitalization. The national rate was 12.7 hospitalizations per 100,000 children. Young adolescents aged 10-13 years accounted for the highest percentage of cases (36.6%) followed by children aged 6-9 years (25.1%). Most patients were male (76.7%) and resided in an urban area (94.4%). A head injury was diagnosed in one out of three hospitalized bicyclists; 30% were due to a motor vehicle collision. CONCLUSIONS: Pediatric bicycle-related hospitalizations are a significant public health problem. The morbidity and mortality among children and the economic costs to society are large. The patient characteristics and injury types identified by this study should be used to develop targeted prevention strategies. (+info)
Area socioeconomic status and childhood injury morbidity in New South Wales, Australia.
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OBJECTIVE: To explore the relationship between child injury morbidity and socioeconomic status. DESIGN: A cross-sectional analysis of routinely collected hospital separation data for unintentional injury for the period 1999/2000-2004/2005. SETTING: All statistical local areas of New South Wales (NSW), Australia SUBJECTS: 110 549 unintentional injury-related hospital separations for NSW children aged 0-14 years. MAIN OUTCOME MEASURE: Adjusted incidence rate ratios (IRRs) for hospital separations for unintentional injury (for all injury and by individual injury mechanisms) by quintile of socioeconomic disadvantage for children aged 0-14 years. RESULTS: There was no clear relationship between socioeconomic status and injury when all injury mechanisms were combined. However, children in the more disadvantaged quintiles were more likely to be hospitalized than children in the least disadvantaged quintile for the following injury mechanisms: motor cycle (point estimates for IRRs across the socioeconomic status quintiles ranged from 2.95 to 4.02 relative to the least disadvantaged quintile), motor-vehicle occupant (IRR range 1.33-2.27), pedestrian (IRR range 1.43-2.54 for ages 0-4 years), pedal cyclist (IRR range 1.30-1.50), fire and burns (IRR range 1.37-2.00), and poisoning (IRR range 1.32-1.91). Similarly, hospital separation rates for foreign body, other transport, and pedestrian (aged 5-9 years) injuries were also greater, but the differences were not statistically significant across all quintiles. These injury mechanisms accounted for about 25% of the hospital separations. CONCLUSIONS: The relationship between relative socioeconomic disadvantage and injury risk in NSW children is strongest for transport-related injuries, fires and burns, and poisoning. Interventions that address these specific injury mechanisms may help to reduce the disparity between high and lower socioeconomic groups. (+info)
Pediatric patient safety events during hospitalization: approaches to accounting for institution-level effects.
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OBJECTIVE: To determine the rates, patient, and institutional characteristics associated with the occurrence of patient safety indicators (PSIs) in hospitalized children and the degree of statistical difference derived from using three approaches of controlling for institution level effects. DATA SOURCE: Pediatric Health Information System Dataset consisting of all pediatric discharges (<21 years of age) from 34 academic, freestanding children's hospitals for calendar year 2003. METHODS: The rates of PSIs were computed for all discharges. The patient and institutional characteristics associated with these PSIs were calculated. The analyses sequentially applied three increasingly conservative methods to control for the institution-level effects robust standard error estimation, a fixed effects model, and a random effects model. The degree of difference from a "base state," which excluded institution-level variables, and between the models was calculated. The effects of these analyses on the interpretation of the PSIs are presented. PRINCIPAL FINDINGS: PSIs are relatively infrequent events in hospitalized children ranging from 0 per 10,000 (postoperative hip fracture) to 87 per 10,000 (postoperative respiratory failure). Significant variables associated PSIs included age (neonates), race (Caucasians), payor status (public insurance), severity of illness (extreme), and hospital size (>300 beds), which all had higher rates of PSIs than their reference groups in the bivariable logistic regression results. The three different approaches of adjusting for institution-level effects demonstrated that there were similarities in both the clinical and statistical significance across each of the models. CONCLUSIONS: Institution-level effects can be appropriately controlled for by using a variety of methods in the analyses of administrative data. Whenever possible, resource-conservative methods should be used in the analyses especially if clinical implications are minimal. (+info)