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Research Articles

Technology-Dependent Pediatric Inpatients at Children’s Versus Nonchildren’s Hospitals

Namrata Ahuja, Wendy J. Mack and Christopher J. Russell
Hospital Pediatrics June 2020, 10 (6) 481-488; DOI: https://doi.org/10.1542/hpeds.2019-0236
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Abstract

BACKGROUND AND OBJECTIVE: Technology-dependent children (TDC) are admitted to both children’s hospitals (CHs) and nonchildren’s hospitals (NCHs), where there may be fewer pediatric-specific specialists or resources. Our objective was to compare the characteristics of TDC admitted to CHs versus NCHs.

METHODS: This was a multicenter, retrospective study using the 2012 Kids’ Inpatient Database. We included patients aged 0 to 18 years with a tracheostomy, gastrostomy, and/or ventricular shunt. We excluded those who died, were transferred into or out of the hospital, had a length of stay (LOS) that was an extreme outlier, or had missing data for key variables. We compared patient and hospital characteristics across CH versus NCH using χ2 tests and LOS and cost using generalized linear models.

RESULTS: In the final sample of 64 521 discharges, 55% of discharges of TDC were from NCHs. A larger proportion of those from CHs had higher disease severity (55% vs 49%; P < .001) and a major surgical procedure during hospitalization (28% vs 24%; P < .001). In an adjusted generalized linear model, the mean LOS was 4 days at both hospital types, but discharge from a CH was associated with a higher adjusted mean cost ($16 754 vs $12 023; P < .001).

CONCLUSIONS: Because the majority of TDC are hospitalized at NCHs, future research on TDC should incorporate NCH settings. Further studies should investigate if some may benefit from regionalization of care or earlier transfer to a CH.

Children who require inpatient admission are cared for at diverse hospital types, ranging from specialized children’s hospitals (CHs) to urban and rural nonchildren’s hospitals (NCHs). The majority of pediatric admissions occur at NCHs.1,2

There has been movement toward regionalization of pediatric health care for specific patient populations, such as neonatal intensive care3 and pediatric trauma care.4–6 Regionalization refers to the directing of patients with specific conditions to specialized hospitals, with the hypothesis being that regional centers of excellence with pediatric-specific medical and ancillary services provide better care.7 Conversely, regionalization may burden families who live further away from specialty hospitals.8,9 Parents, providers, and insurers have an interest in identifying children who can receive quality care at closer-to-home NCHs and children who would be better served at a tertiary or quaternary specialty CH.

Children with medical complexity account for a large proportion of pediatric inpatient admissions10,11and have a longer length of stay (LOS) and increased costs of hospitalization.11 Although children with medical complexity often receive care at specialty CHs, a 2006 study showed that 37% of children with ≥1 complex chronic condition (CCC) are hospitalized at NCHs.11 A large subset of children with medical complexity rely on the use of medical technology such as a gastrostomy tube or tracheostomy to sustain life or improve functioning.11–13 Often multiple medical specialists and health care professionals, such as pediatric respiratory therapists, may be involved in the care of technology-dependent children (TDC) who are admitted to CHs12; however, these resources may not be available at an NCH. Given these differential resources, TDC may be a subgroup that benefits from regionalization of care, and TDC may have better outcomes at specialized CHs.

To our knowledge, no previous studies have compared characteristics of TDC at CHs versus at NCHs and the association of hospital type with outcomes such as LOS or cost. Understanding the differences in baseline characteristics as well as outcomes between these 2 groups will help direct where future research for this population is conducted as well as whether this population, or a portion of it, may benefit from regionalization of care.

Methods

Data Source and Sample

This was a multicenter, retrospective, cross-sectional study using data from the 2012 Kids’ Inpatient Database (KID 2012), which is a national administrative data set with a sample of inpatients from ages 0 to 20 who were discharged in 2012 from all community, nonrehabilitation hospitals in 44 participating states in the United States. It is part of a family of databases that were developed for the Healthcare Cost and Utilization Project (HCUP), which is sponsored by the Agency for Healthcare Research and Quality.14

We selected a study sample from KID 2012 (Fig 1) that included any patient aged 0 to 18 with discharge International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes used in Feudtner et al’s15 CCC classification system and previous studies16–21 consistent with at least 1 of the following technologies: tracheostomy (V44.0, V55.0, 519.0, 519.00, 519.01, 519.02, or 519.09), gastrostomy (with or without jejunostomy; V44.1, V55.1, or 536.4), or ventricular shunt (V45.2, V53.01, 996.2, or 996.63). We focused on these 3 technology types because they are among the most prevalent, in our clinical experience. We excluded those whose final disposition was deceased because LOS was 1 of our outcomes of interest. For our primary analyses, the “Transfer In” and “Transfer Out” indicator provided in KID 2012 was used to exclude discharges of patients who had been transferred into or out of a different acute care hospital than the hospital at discharge, again because LOS was 1 of our outcomes of interest and the database does not report LOS before a transfer. Discharges with a LOS that was an extreme outlier (>18 days), calculated as 3 times the interquartile range (IQR) from the median, were excluded from the sample. Additionally, we excluded discharges of patients who were missing data for key variables (race, sex, median household income, payer, All Patient Refined Diagnosis Related Group Severity of Illness score, and charge).

FIGURE 1
FIGURE 1

Flowchart depicting sample selection and inclusion and exclusion criteria. a The sample was weighted by using a weighting variable provided in the KID 2012 to obtain national estimates from the raw data.

This project was deemed exempt by our hospital’s institutional review board (per 45 Code of Federal Regulations 46.102[f]).

Hospital Type

The primary predictor was the hospital type of each discharge: CH versus NCH. KID 2012 uses information from the American Hospital Association Annual Survey as well as the National Association of Children’s Hospitals and Related Institutions (now known as the Children’s Hospital Association) to define CHs, which include freestanding CHs as well as pediatric units within general hospitals.22 All hospitals not defined as CHs by using KID 2012 were defined as NCHs.

Patient Demographics

Patient demographics studied included age (in years), sex, race (categorized as non-Hispanic white, non-Hispanic African American, Hispanic, and other), median household income for the patient’s zip code (categorized in quartiles), payer (categorized as public insurance, private insurance, and other), and the size of the patient’s county of residence (categorized as central or fringe counties of a metropolitan area with a population >1 million, counties of a metropolitan area with populations of 50 000–999 999, and micropolitan counties and/or nonmetropolitan counties).

Patient Clinical Characteristics

Patient clinical characteristics studied included type of technology (tracheostomy, gastrostomy, or ventricular shunt), number of technologies, CCCs (as defined by Feutdner et al15), and whether a major operating-room procedure occurred during admission (defined [by an indicator provided in KID 2012] as a therapeutic or diagnostic procedure that occurred in an operating room, which could include placement of a tracheostomy, gastrostomy, or ventricular shunt). As a proxy measure for complexity, we used the number of CCCs, and for severity of illness, we used the Hospitalization Resource Intensity Score for Kids (H-RISK), which is calculated by using cost and All Patient Refined Diagnosis Related Group Severity of Illness score.23 H-RISK scores compare the relative intensity of hospital care for inpatient pediatric populations, with a higher score demonstrating a higher intensity of care. Scores can range from as low as 0.18 (normal newborn) to as high as 91.66 (heart and/or lung transplant).

Hospital Demographics

Hospital demographics studied included hospital region (Northeast, Midwest, South, and West), teaching and urban versus rural status (rural, urban teaching, and urban nonteaching), and hospital-bed size category (small, medium, and large), which is categorized by HCUP and specific to the hospital’s location and teaching status.14 Urban hospitals are identified as those in a core-based statistical area as defined by the US Census Bureau, and all other hospitals are defined as rural.

Primary Admission Diagnoses

KID 2012 provides a primary admission diagnosis ICD-9-CM code for each subject and additionally provides a Clinical Classifications Software, which collapses codes into clinically meaningful categories of diagnoses.24 HCUP determines the discharge diagnosis thought to be chiefly responsible for causing the admission of the patient, and defines this as the primary admission diagnosis. The primary Clinical Classifications Software diagnosis for all discharges was studied.

Outcome Measures

The primary outcome of interest was the proportion of patient discharges at each hospital type by patient demographics and clinical and hospital characteristics. Secondary outcomes were LOS in days and estimated cost in dollars for each hospital type. Cost was estimated from charge data provided for each discharge by using hospital-specific cost/charge ratios provided by HCUP.25 These ratios were obtained by using cost data that hospitals provided to the Centers for Medicare and Medicaid Services. Among all hospitals in KID 2012, the median cost/charge ratio is 0.39 with an IQR 0.28 to 0.60.

Statistical Analyses

All analyses reflected the KID 2012 complex sampling design; the stratification, hospital-level clustering, and sampling-weight variables from the KID 2012 database, as well as the definition of the specified study group (TDC) as a study subpopulation, were used to obtain national estimates as well as SEs and 95% confidence intervals. We conducted bivariate analyses to assess the relationships between hospital type and all other variables. Descriptive statistics generated national estimates of numbers and proportions (with 95% confidence intervals) of TDC by patient demographics, patient clinical characteristics, and hospital characteristics in CHs and NCHs. Differences in proportions on each characteristic between CHs and NCHs were statistically tested with a Pearson’s χ2 test statistic that was corrected for the survey design effects and reported as an F-statistic.

Generalized linear models were used to estimate the association between hospital type and the dependent outcome variables of LOS and cost. LOS used a negative binomial regression (negative binomial random variable, log link function); cost used a gamma regression (gamma random variable, log link function). The stratification, clustering, sampling weight, and subpopulation variables were incorporated into the analysis to provide appropriate estimates of SEs. Associations are presented as exponentiated regression estimates with 95% confidence intervals; exponentiated regression coefficients for these models represent the fold difference (ie, ratio) in the covariate-adjusted mean LOS (or cost) in discharges from CHs compared with NCHs. Covariates used in the adjusted LOS and cost models included hospital type (CH versus NCH), age, sex, race, household income, payer, H-RISK, number of technologies, number of CCCs, hospital region, major operating-room procedures, and hospital location and/or teaching status. Our cost model also included LOS as a covariate.

All analyses used 2-tailed tests with a significance level of 0.05. Statistical analysis was conducted by using Stata software (version 15; Stata Corp, College Station, TX) for survey data analysis.

Results

Study Population

Of 6.7 million discharges in KID 2012, 64 521 met all of our inclusion and exclusion criteria. The majority of discharges of TDC were from NCHs (n = 35 430; 55%). The discharges in our study came from 1408 hospitals, and 1345 (95.5%) were NCHs. Most NCHs were rural (23.3%; n = 314) or urban nonteaching (39.0%; n = 524) versus urban teaching (37.7%; n = 507). There were no rural CHs, and most were urban teaching hospitals (88.9%; n = 56). When compared with NCHs, CHs had higher mean numbers of discharges in a year for children with tracheostomies (91 vs 5), gastrostomy tubes (320 vs18), and ventricular shunts (143 vs 8).

Patient Demographics

The study sample was primarily male (55.2%; n = 35 622), non-Hispanic white (53.4%; n = 34 422), and on public insurance (59.3%; n = 38 232) and had a median age of 4 years (IQR 2–10 years). Most patient demographics were similar between CHs and NCHs (Table 1), although NCHs had a higher proportion <5 years of age (56.6% vs 53.7%; P < .001), and CHs had a higher proportion from the counties of large metropolitan areas (66.9% vs 50.8%; P = .005).

View this table:
TABLE 1

Patient, Clinical, and Hospital Characteristics of Discharges of Nontransferred TDC From NCHs Versus CHs

Patient Clinical Characteristics

Of the entire sample, 19.8% (n = 12 749) of TDC had tracheostomies, 69% (n = 44 523) had gastrostomy tubes, and 31% (n = 20 019) had ventricular shunts, with the majority having only 1 technology type (81.5%; n = 52 590). There was no difference in the proportion of types of technologies or the number of technologies between CHs and NCHs (Table 1). TDC at CHs had higher H-RISK scores (P < .001) and were more likely to have a major operating-room procedure during hospitalization (27.9% vs 23.9%; P < .001). The proportions of different CCCs were similar between NCHs and CHs (Table 1), and gastrointestinal, neuromuscular, and respiratory CCCs were the most common. The top 5 primary diagnoses at CHs and NCHs were similar (Supplemental Table 4), with the most frequent being “complications of a device and/or implant.”

LOS

On bivariate negative binomial regression analysis, there was a statistically significant but small absolute difference in mean LOS at NCHs versus CHs (4.26 days versus 4.49 days; P = .002; Table 2).When controlling for differences in demographics, clinical characteristics, and hospital characteristics, there continued to be a statistically significant but small absolute difference between NCH versus CH admission and adjusted mean estimated LOS (4.31 days versus 4.44 days; P = .048; Table 2).

View this table:
TABLE 2

Unadjusted and Multivariable-Adjusted Negative Binomial Regression Model of the Association Between Hospital Type and LOS

Estimated Total Hospitalization Cost

On bivariate gamma regression analysis, there was significantly increased mean cost, calculated from charges, at CHs versus NCHs ($17 621 vs $11 266; P < .001; Table 3). When controlling for differences in demographics, clinical characteristics, and hospital characteristics in our generalized linear (gamma regression) model, the estimated mean cost remained higher at CHs ($16 754 vs $12 023; P < .001; Table 3).

View this table:
TABLE 3

Unadjusted and Multivariable-Adjusted Gamma Regression Model of the Association Between Hospital Type and Cost

Discussion

In this cross-sectional retrospective cohort study of 64 521 pediatric discharges in 2012 with tracheostomy, gastrostomy, and/or ventricular shunt dependence, the majority of TDC were discharged from NCHs. Because of the large number of NCHs compared with CHs, the average number of TDC discharges per NCH was lower than per CH, indicating a lower rate of exposure to this population at NCHs. TDC discharges from CHs tended to have higher illness severity and higher rates of surgical procedures. Even after controlling for severity and surgical procedures, TDC discharges from CHs had a similar LOS but higher cost than discharges from NCHs.

We showed that a larger number of TDC are discharged from NCHs. We were unable to find previous literature that looks specifically at TDC at CHs versus NCHs to compare our findings; however, in a previous study of children with CCCs, the majority with 1 or more CCCs were discharged from CHs.11 This difference suggests that TDC, a subset of children with CCCs, are more commonly discharged from NCHs, whereas TDC with other types of CCCs may be more likely to be seen in a CH setting. This has important implications for how and where research is conducted for TDC. For example, research that is done at a CHs or that uses sources such as the Pediatric Health Information System database, a database with information from CHs only, would be missing data from where the majority of these children are actually seen. This could have significant implications on the generalizability of such research.

Additionally, our finding that TDC are seen more often at NCHs but individual NCHs have a low rate of exposure to TDC has important implications for the care of TDC. Smaller-volume NCHs should consider how to maintain adequate staffing and proficiency to care for TDC or may find it is more feasible to regionalize their care and transfer the TDC with rare conditions to the closest CHs. Current Pediatric Hospital Medicine Core Competencies include the care of TDC,26 and these competencies should be part of the training of pediatric hospitalist fellows27 as well as ongoing education for hospitalists to maintain the skills to care for this population regardless of hospital setting.

Our study found similar LOS but higher cost at CHs versus NCHs. Many previous studies have shown higher charges or costs at CHs versus NCHs for all pediatric inpatients,28 pediatric asthma,29,30 severe pediatric sepsis,31 and common surgical procedures.32–37 Some show equivalent outcomes regardless of hospital type, such as for malrotation surgery38 and neonatal herpes simplex.7 Others show poorer outcomes at non-CHs, such as increased LOS and complications with pyloromyotomy.39,40 CHs may have services that are not found at NCHs that contribute to higher costs, such as specialized equipment or ancillary staff. On the other hand, there could be many mediating and unmeasured confounding factors that play into cost that cannot be assessed by using the KID 2012. For example, severity measures available in the KID 2012 may have not completely accounted for the higher disease severity of patients at CHs. Further studies should assess for these factors; if the cost differential is true, studies should investigate if the increased costs lead to better clinical outcomes, such as decreased readmission rates, ICU use, or mortality at CHs.

In our study, TDC received care at NCHs without an increase in LOS and at a lower cost. However, given the low exposure of individual NCHs to TDC, there may be subgroups of TDC, such as those who are more severely ill or have more complicated illnesses, who may benefit from regionalization of care to a CH. Future studies should assess clinical outcomes other than LOS and cost for TDC and further define which subpopulations may benefit most from regionalization of care.

There are several limitations in the current study. KID 2012 is an administrative database based on billing data and therefore contains limited clinical information. KID 2012 does not contain detailed information on different hospital characteristics or resources, such as whether a specific NCH might have a PICU or be affiliated with and staffed by a CH. Additionally, KID 2012 does not provide readmission data or unique patient identifiers, so we were unable to account for potential multiple discharges of the same child. Our study relied on the use of ICD-9-CM codes to identify patients who were billed for having tracheostomies, gastrostomies, and ventricular shunts, which may not have been accurately coded by the medical coders; therefore, our study may have underestimated the true prevalence of technology dependence. The ICD-9-CM codes we used have been used in previous studies using administrative data16–21; however, use of these codes could have overestimated or underestimated our rates of technology dependence as well. We are dependent on the classification that has been provided by the database for CHs versus NCHs, and there is potential for misclassification. These limitations are balanced by some important strengths of our study. Firstly, the large sample size in the KID 2012 data set is an important prerequisite to study this relatively rare population of TDC. This is further enhanced by the complex survey design with weighted variables provided in KID 2012 that can be used to calculate national estimates. Secondly, the KID 2012 is unique compared with many other data sources in that it provides information from both CHs and NCHs.

Conclusions

We have demonstrated that the majority of TDC are discharged from NCHs; however, individual NCHs have a lower rate of exposure to TDC than CHs do. Although the patient demographics, clinical characteristics, hospital characteristics, and LOS are fairly similar across hospital types, TDC at CHs have a higher severity of illness and are more likely to have a major operating-room procedure during hospitalization. Even when accounting for these clinical differences, discharge from a CH is associated with higher cost. Future studies should identify subgroups of TDC who might benefit from regionalization of their care.

Acknowledgments

We acknowledge clinical research assistant Amir Hassan, BA, for his help in creating and formatting the tables for this article.

Footnotes

  • FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

  • FUNDING: Supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (grants UL1TR001855 and UL1TR000130). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Funded by the National Institutes of Health (NIH).

  • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

References

  1. ↵
    1. Colvin JD,
    2. Hall M,
    3. Gottlieb L,
    4. et al
    . Hospitalizations of low-income children and children with severe health conditions: implications of the Patient Protection and Affordable Care Act. JAMA Pediatr. 2016;170(2):176–178
    OpenUrl
  2. ↵
    1. Leyenaar JK,
    2. Ralston SL,
    3. Shieh MS,
    4. Pekow PS,
    5. Mangione-Smith R,
    6. Lindenauer PK
    . Epidemiology of pediatric hospitalizations at general hospitals and freestanding children’s hospitals in the United States. J Hosp Med. 2016;11(11):743–749
    OpenUrlPubMed
  3. ↵
    1. Rashidian A,
    2. Omidvari AH,
    3. Vali Y,
    4. et al
    . The effectiveness of regionalization of perinatal care services—a systematic review. Public Health. 2014;128(10):872–885
    OpenUrl
  4. ↵
    1. Acosta CD,
    2. Kit Delgado M,
    3. Gisondi MA,
    4. et al
    . Characteristics of pediatric trauma transfers to a level i trauma center: implications for developing a regionalized pediatric trauma system in California. Acad Emerg Med. 2010;17(12):1364–1373
    OpenUrlCrossRefPubMed
  5. American Academy of PediatricsCommittee on Pediatric Emergency MedicineAmerican College of Critical Care MedicineSociety of Critical Care Medicine. Consensus report for regionalization of services for critically ill or injured children. Pediatrics. 2000;105(1, pt 1):152–155
    OpenUrlAbstract/FREE Full Text
  6. ↵
    1. Wesson DE
    . Pediatric trauma centers: coming of age. Tex Heart Inst J. 2012;39(6):871–873
    OpenUrl
  7. ↵
    1. Lorch SA,
    2. Millman AM,
    3. Shah SS
    . Impact of congenital anomalies and treatment location on the outcomes of infants hospitalized with herpes simplex virus (HSV). J Hosp Med. 2010;5(3):154–159
    OpenUrlPubMed
  8. ↵
    1. Mayer ML
    . Disparities in geographic access to pediatric subspecialty care. Matern Child Health J. 2008;12(5):624–632
    OpenUrlCrossRefPubMed
  9. ↵
    1. Chang R-KR,
    2. Joyce JJ,
    3. Castillo J,
    4. Ceja J,
    5. Quan P,
    6. Klitzner TS
    . Parental preference regarding hospitals for children undergoing surgery: a trade-off between travel distance and potential outcome improvement. Can J Cardiol. 2004;20(9):877–882
    OpenUrlPubMed
  10. ↵
    1. Burns KH,
    2. Casey PH,
    3. Lyle RE,
    4. Bird TM,
    5. Fussell JJ,
    6. Robbins JM
    . Increasing prevalence of medically complex children in US hospitals. Pediatrics. 2010;126(4):638–646
    OpenUrlAbstract/FREE Full Text
  11. ↵
    1. Simon TD,
    2. Berry J,
    3. Feudtner C,
    4. et al
    . Children with complex chronic conditions in inpatient hospital settings in the United States. Pediatrics. 2010;126(4):647–655
    OpenUrlAbstract/FREE Full Text
  12. ↵
    1. Simon TD,
    2. Mahant S,
    3. Cohen E
    . Pediatric hospital medicine and children with medical complexity: past, present, and future. Curr Probl Pediatr Adolesc Health Care. 2012;42(5):113–119
    OpenUrlCrossRefPubMed
  13. ↵
    1. Caicedo C
    . Children with special health care needs: child health and functioning outcomes and health care service use. J Pediatr Health Care. 2016;30(6):590–598
    OpenUrl
  14. ↵
    HCUP. Overview of the Kids’ Inpatient Database (KID). 2012. Available at: www.hcup-us.ahrq.gov/kidoverview.jsp. Accessed March 30, 2017
  15. ↵
    1. Feudtner C,
    2. Feinstein JA,
    3. Zhong W,
    4. Hall M,
    5. Dai D
    . Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14(1):199
    OpenUrlCrossRefPubMed
  16. ↵
    1. Russell CJ,
    2. Mack WJ,
    3. Schrager SM,
    4. Wu S
    . Care variations and outcomes for children hospitalized with bacterial tracheostomy-associated respiratory infections. Hosp Pediatr. 2017;7(1):16–23
    OpenUrlAbstract/FREE Full Text
    1. Russell CJ,
    2. Simon TD,
    3. Mamey MR,
    4. Newth CJL,
    5. Neely MN
    . Pseudomonas aeruginosa and post-tracheotomy bacterial respiratory tract infection readmissions. Pediatr Pulmonol. 2017;52(9):1212–1218
    OpenUrl
    1. Berry JG,
    2. Graham RJ,
    3. Roberson DW,
    4. et al
    . Patient characteristics associated with in-hospital mortality in children following tracheotomy. Arch Dis Child. 2010;95(9):703–710
    OpenUrlAbstract/FREE Full Text
    1. Berry JG,
    2. Graham DA,
    3. Graham RJ,
    4. et al
    . Predictors of clinical outcomes and hospital resource use of children after tracheotomy. Pediatrics. 2009;124(2):563–572
    OpenUrlAbstract/FREE Full Text
    1. Barnhart DC,
    2. Hall M,
    3. Mahant S,
    4. et al
    . Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatr. 2013;167(10):911–918
    OpenUrl
  21. ↵
    1. Srivastava R,
    2. Berry JG,
    3. Hall M,
    4. et al
    . Reflux related hospital admissions after fundoplication in children with neurological impairment: retrospective cohort study. BMJ. 2009;339:b4411
    OpenUrlAbstract/FREE Full Text
  22. ↵
    Children’s Hospital Association. Available at: https://www.childrenshospitals.org/Directories/Hospital-Directory. Accessed March 16, 2017
  23. ↵
    1. Richardson T,
    2. Rodean J,
    3. Harris M,
    4. Berry J,
    5. Gay JC,
    6. Hall M
    . Development of Hospitalization Resource Intensity Scores for Kids (H-RISK) and comparison across pediatric populations. J Hosp Med. 2018;13(9):602–608
    OpenUrlPubMed
  24. ↵
    HCUP. Clinical Classifications Software (CCS) for ICD-9-CM. Healthcare Cost and Utilization Project (HCUP). Rockville, MD; Agency for Healthcare Research and Quality; 2012. Available at: www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp. Accessed March 30, 2017
  25. ↵
    HCUP. Cost-to-Charge Ratio Files (CCR). Healthcare Cost and Utilization Project (HCUP). Rockville, MD; Agency for Healthcare Research and Quality; 2012. Available at: www.hcup-us.ahrq.gov/db/state/costtocharge.jsp. Accessed March 17, 2017
  26. ↵
    1. Stucky ER,
    2. Maniscalco J,
    3. Ottolini MC,
    4. et al
    . The Pediatric Hospital Medicine Core Competencies supplement: a framework for curriculum development by the society of hospital medicine with acknowledgement to pediatric hospitalists from the American Academy of Pediatrics and the Academic Pediatric Association. J Hosp Med. 2010;5(suppl 2):i–xv, 1–114
    OpenUrlCrossRefPubMed
  27. ↵
    1. Jerardi KE,
    2. Fisher E,
    3. Rassbach C,
    4. et al
    ; Council of Pediatric Hospital Medicine Fellowship Directors. Development of a curricular framework for pediatric hospital medicine fellowships. Pediatrics. 2017;140(1):e20170698
    OpenUrlAbstract/FREE Full Text
  28. ↵
    1. Merenstein D,
    2. Egleston B,
    3. Diener-West M
    . Lengths of stay and costs associated with children’s hospitals. Pediatrics. 2005;115(4):839–844
    OpenUrlAbstract/FREE Full Text
  29. ↵
    1. Gupta RS,
    2. Bewtra M,
    3. Prosser LA,
    4. Finkelstein JA
    . Predictors of hospital charges for children admitted with asthma. Ambul Pediatr. 2006;6(1):15–20
    OpenUrlCrossRefPubMed
  30. ↵
    1. Macy ML,
    2. Stanley RM,
    3. Sasson C,
    4. Gebremariam A,
    5. Davis MM
    . High turnover stays for pediatric asthma in the United States: analysis of the 2006 Kids’ Inpatient Database. Med Care. 2010;48(9):827–833
    OpenUrlCrossRefPubMed
  31. ↵
    1. Odetola FO,
    2. Gebremariam A,
    3. Freed GL
    . Patient and hospital correlates of clinical outcomes and resource utilization in severe pediatric sepsis. Pediatrics. 2007;119(3):487–494
    OpenUrlAbstract/FREE Full Text
  32. ↵
    1. Raol N,
    2. Zogg CK,
    3. Boss EF,
    4. Weissman JS
    . Inpatient pediatric tonsillectomy: does hospital type Affect cost and outcomes of care? Otolaryngol Head Neck Surg. 2016;154(3):486–493
    OpenUrlCrossRefPubMed
    1. Tom CM,
    2. Won RP,
    3. Friedlander S,
    4. Sakai-Bizmark R,
    5. de Virgilio C,
    6. Lee SL
    . Impact of children’s hospital designation on outcomes and costs after cholecystectomy in adolescent patients. Am Surg. 2018;84(10):1547–1550
    OpenUrl
    1. Tom CM,
    2. Won RP,
    3. Lee AD,
    4. Friedlander S,
    5. Sakai-Bizmark R,
    6. Lee SL
    . Outcomes and costs of common surgical procedures at children’s and nonchildren’s hospitals. J Surg Res. 2018;232:63–71
    OpenUrl
    1. Short HL,
    2. Sarda S,
    3. Travers C,
    4. Hockenberry J,
    5. McCarthy I,
    6. Raval MV
    . Pediatric inpatient-status volume and cost at children’s and nonchildren’s hospitals in the United States: 2000-2009. Hosp Pediatr. 2018;8(12):753–760
    OpenUrlAbstract/FREE Full Text
    1. Short HL,
    2. Sarda S,
    3. Travers C,
    4. Hockenberry JM,
    5. McCarthy I,
    6. Raval MV
    . Trends in common surgical procedures at children’s and nonchildren’s hospitals between 2000 and 2009. J Pediatr Surg. 2018;53(8):1472–1477
    OpenUrl
  37. ↵
    1. Tian Y,
    2. Heiss KF,
    3. Wulkan ML,
    4. Raval MV
    . Assessment of variation in care and outcomes for pediatric appendicitis at children’s and non-children’s hospitals. J Pediatr Surg. 2015;50(11):1885–1892
    OpenUrlCrossRefPubMed
  38. ↵
    1. Kulaylat AN,
    2. Hollenbeak CS,
    3. Engbrecht BW,
    4. Dillon PW,
    5. Safford SD
    . The impact of children’s hospital designation on outcomes in children with malrotation. J Pediatr Surg. 2015;50(3):417–422
    OpenUrl
  39. ↵
    1. Kelley-Quon LI,
    2. Tseng CH,
    3. Jen HC,
    4. Shew SB
    . Hospital type predicts surgical complications for infants with hypertrophic pyloric stenosis. Am Surg. 2012;78(10):1079–1082
    OpenUrlPubMed
  40. ↵
    1. Raval MV,
    2. Cohen ME,
    3. Barsness KA,
    4. Bentrem DJ,
    5. Phillips JD,
    6. Reynolds M
    . Does hospital type affect pyloromyotomy outcomes? Analysis of the Kids’ Inpatient Database. Surgery. 2010;148(2):411–419
    OpenUrlCrossRefPubMed
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Technology-Dependent Pediatric Inpatients at Children’s Versus Nonchildren’s Hospitals
Namrata Ahuja, Wendy J. Mack, Christopher J. Russell
Hospital Pediatrics Jun 2020, 10 (6) 481-488; DOI: 10.1542/hpeds.2019-0236
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