In 2022, a New York Times headline declared, “Saving kids is bad business in America.”1 Pediatric hospitalists were faced with an unprecedented winter surge due to the “tripledemic” of COVID-19, influenza, and respiratory syncytial virus. Meanwhile, hospitals nationwide closed their pediatric units to focus resources on adult care.2
Outside of the hospital, children and families around the world were impacted by social inequities and humanitarian crises in the form of rising inflation, Russia’s invasion of Ukraine, and intensifying climate change.
As pediatric hospitalists, we’ve had the privilege to walk briefly alongside our patients and their families to help them navigate a challenging year. We’ve continued to ask ourselves how we can provide better care and have published literature to help us continue to cultivate our field.
In this article, we identify the top 10 articles that impacted pediatric hospital medicine in 2022, as presented at the Pediatric Update at SHM Converge 2023 in Austin, Texas. Four of the articles are summarized here.
Surge in Pediatric Firearm Injuries Presenting to US Children’s Hospitals During the COVID-19 Pandemic
Iantorno SE, et al. Surge in pediatric firearm injuries presenting to us children’s hospitals during the COVID-19 pandemic. JAMA Pediatr. 2023;177(2):204-6.
Background—Firearm injury is a leading and preventable cause of death for youth in the U.S.3 In order to develop effective and evidence-based prevention strategies, it’s imperative to first understand the current trends in mortality data, with a particular focus on intent, differences by age group, and racial or ethnic inequities.
Findings—This multicenter retrospective cohort study used data from the Pediatric Health Information System to compare a cohort from April 2018-December 2019 to April 2020-December 2021. It included all children younger than 18 years diagnosed with firearm injury based on International Classification of Diseases, Tenth Revision codes. The primary outcome was monthly firearm-injury rate. There were 1,815 firearm injuries before versus 2,759 during the pandemic, a 52% increase. A greater proportion of non-Hispanic Black children, those aged 0 to 5 years, and those with public insurance had firearm injuries during the pandemic. There were no significant differences between cohorts by sex, household income, rurality, region, mortality, or intent.
Practice Implications—This study shows a surge in pediatric firearm injuries presenting to US children’s hospitals during the COVID-19 pandemic. The unequal rates of injury in black children and children with public insurance reflects the disproportionate impact of COVID-19 in minority groups due to the exacerbation of previously present healthcare disparities. This data should be used to support advocacy efforts and healthcare policy aimed at injury prevention.
Common Diagnoses and Costs in Pediatric Hospitalization in the U.S.
Kaiser SV, et al. Common diagnoses and costs in pediatric hospitalization in the US. JAMA Pediatr. 2022;176(3):316-18.
Background—As the Choosing Wisely: Things We Do for No Reason series highlighted, low-value care practices continue to propagate because “that is how we have always done it.”4 More evidence is needed to guide high-value inpatient pediatric care, and a crucial initial step is to determine the costliest and most common reasons for hospitalization.
Findings—This study was a cross-sectional analysis of data from the 2016 (most recent available) Kids’ Inpatient Database. It included all nonbirth hospital discharges for children aged 0 to 17 years and excluded any records for which the primary diagnosis was missing. They reviewed 1,777,023 nonbirth pediatric hospitalizations in 3,768 U.S. hospitals. The most common diagnoses were bronchiolitis (n=97,564 hospitalizations), pneumonia (n=86,702 hospitalizations), asthma (n=84,436 hospitalizations), major depressive disorder (n=79,147 hospitalizations), and cellulitis (n=42,556 hospitalizations). The costliest diagnoses overall were respiratory failure ($982.8 million), pneumonia ($785 million), chemotherapy ($781.4 million), bronchiolitis ($702.2 million), and septicemia ($697 million).
Practice Implications—Research and quality-improvement efforts focused on bronchiolitis, pneumonia, asthma, and septicemia could lead to significant impacts in the field of pediatric hospital medicine. Notably, the investigators found that major depressive disorder increased from the ninth most common diagnosis in 2012 to the fourth most common in 2016.5 Research has shown that the COVID-19 pandemic led to an even greater increase in hospitalization due to mental health disorders.6 Thus, this study emphasizes the dire need for resources for children who are hospitalized with mental health disorders.
The Increasing Proportion of Adult Discharges at Children’s Hospitals, 2004-2019
Allen AQ, et al. The increasing proportion of adult discharges at children’s hospitals, 2004-2019. J Hosp Med. 2022;17(12):990-3.
Background—Due to medical advances, patients with chronic complex medical conditions can live further into adulthood. Due to multiple factors, this population faces challenges transitioning to adult care.7
Findings—This multicenter retrospective cohort study used data from the Pediatric Health Information System. It included all observation and inpatient encounters from 2004-2019 except newborn and pregnancy-related encounters; 8,097,081 encounters were identified. The study showed that adults discharged from children’s hospitals are more likely to have a complex chronic condition, higher length of stay, and higher median cost compared to other children. Additionally, the number of adult admissions to children’s hospitals continues to increase, especially among the 21–25-year-old age group.
Practice Implications—Future research and health care policy should focus on addressing the needs of the growing adult population in children’s hospitals.
Opportunities for Restructuring Hospital Transfer Networks for Pediatric Asthma
Brown L, et al. Opportunities for restructuring hospital transfer networks for pediatric asthma. Acad Pediatr. 2022;22(1):29-36.
Background—Children with asthma are often transferred to specialized centers for care, and these transfers often result in either immediate discharge from the emergency department or brief admission.8,9 Given the recent surge in pediatric hospitalizations, it is vital to identify opportunities to decrease the burden on tertiary care centers safely.2
Findings—This multicenter, retrospective, cross-sectional study used data from 2014 inpatient and emergency department encounters in Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York. The study included children under the age of 18 with a diagnosis of asthma and identified 174,239 hospital encounters. There were 3,101 transfers, and 94% of these were admitted, with a median length of stay of two days. For 53% of children transferred, there was a closer potentially admitting hospital that was bypassed.
Practice Implications—This study suggests that developing a tiered transfer system among regionally affiliated hospitals for treatment of pediatric asthma patients has the potential to reduce travel burdens on families, lower costs of admission, and reduce patient burden in specialized referral centers.
The remaining articles that comprised the top 10:
Cantey JB, et al. Remote stewardship for medically underserved nurseries: A stepped-wedge, cluster randomized study. Pediatrics. 2022;149(5):e2021055686. doi:10.1542/peds.2021-055686.
Hikmat S, et al. Short intravenous antibiotic courses for urinary infections in young infants: A systematic review. Pediatrics. 2022;149(2):e2021052466. doi:10.1542/peds.2021-052466.
Kemper AR, et al. Clinical practice guideline revision: Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2022;150(3):e2022058859. doi:10.1542/peds.2022-058859.
Qattea I, et al. Neonatal hyperbilirubinemia and bilirubin neurotoxicity in hospitalized neonates: analysis of the US database. Pediatr Res. 2022;91(7):1662-8.
Walsh PS, et al. Association of early oseltamivir with improved outcomes in hospitalized children with influenza, 2007-2020. JAMA Pediatr. 2022;176(11):e223261. doi:10.1001/jamapediatrics.2022.3261.
Wolf RM, et al. Pharmacologic restraint use for children experiencing mental health crises in pediatric hospitals. J Hosp Med. 2023;18(2):120-9.
References
- Stockton A, King L. Opinion: Why Saving Kids Is Bad Business in America. https://www.nytimes.com/2023/01/04/opinion/covid-flu-rsv-children-hospitals.html New York Times; January 4, 2023. Accessed February 28, 2023.
- Baumgaertner, E. New York Times, October 11, 2022, In the News: As Hospitals Close Children’s Units, Where Does That Leave Lachlan? NCBI website. https://www.ncbi.nlm.nih.gov/search/research-news/17339/. Accessed May 30, 2023.
- Lee LK, et al. Crossing lines – a change in the leading cause of death among U.S. children. N Engl J Med. 2022;386(16):1485-7.
- Daniel Wolfson. Celebrating 10 years of Choosing Wisely. ABIM Foundation website. https://abimfoundation.org/blog-post/celebrating-10-years-of-choosing-wisely. Published April 4, 2022. Accessed May 30, 2023.
- Leyenaar JK, et al. Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743-9.
- Krass P, et al. US pediatric emergency department visits for mental health conditions during the COVID-19 pandemic. JAMA Netw Open. 2021;4(4):e218533. doi:10.1001/jamanetworkopen.2021.8533.
- Gray WN, et al. Barriers to transition from pediatric to adult care: a systematic review. J Pediatr Psychol. 2018;43(5):488-502.
- França UL, McManus ML. Trends in regionalization of hospital care for common pediatric conditions. Pediatrics. 2018;141(1):e20171940. doi:10.1542/peds.2017-1940.
- França UL, McManus ML. Assessment of acute hospital use and transfers for management of pediatric seizures. JAMA Netw Open. 2020;3(4):e203148. doi:10.1001/jamanetworkopen.2020.3148.
Dr. Kushnir
Dr. Lauffer
Dr. Lauffer is an assistant professor of internal medicine and pediatrics at the Marshall University Joan C. Edwards School of Medicine and an associate program director of the Marshall Pediatric Hospital Medicine Fellowship Program in Huntington, W.Va. She is a co-chair of the American Academy of Pediatrics HM section’s med-peds subcommittee and chief health officer of Cabell County, W. Va. Schools. Dr. Kushnir is a fellow in pediatric hospital medicine at Phoenix Children’s Hospital in Phoenix, Ariz.