Vaccine Administration in Children’s Hospitals

OBJECTIVES: To examine inpatient vaccine delivery across a national sample of children’s hospitals. METHODS: We conducted a retrospective cohort study examining vaccine administration at 49 children’s hospitals in the Pediatric Health Information System database. Children <18 years old admitted between July 1, 2017, and June 30, 2019, and age eligible for vaccinations were included. We determined the proportion of hospitalizations with ≥1 dose of any vaccine type administered overall and by hospital, the type of vaccines administered, and the demographic characteristics of children who received vaccines. We calculated adjusted hospital-level rates for each vaccine type by hospital. We used logistic and linear regression models to examine characteristics associated with vaccine administration. RESULTS: There were 1 185 667 children and 1 536 340 hospitalizations included. The mean age was 5.5 years; 18% were non-Hispanic Black, and 55% had public insurance. There were ≥1 vaccine doses administered in 12.9% (95% confidence interval: 12.8–12.9) of hospitalizations, ranging from 1% to 45% across hospitals. The most common vaccines administered were hepatitis B and influenza. Vaccine doses other than the hepatitis B birth dose and influenza were administered in 1.9% of hospitalizations. Children had higher odds of receiving a vaccine dose other than the hepatitis B birth dose or influenza if they were <2 months old, had public insurance, were non-Hispanic Black race, were medically complex, or had a length of stay ≥3 days. CONCLUSIONS: In this national study, few hospitalizations involved vaccine administration with substantial variability across US children's hospitals. Efforts to standardize inpatient vaccine administration may represent an opportunity to increase childhood vaccine coverage.

Factors Influencing US Hospital and Medical School Participation in Pediatric COVID-19 Research

BACKGROUND AND OBJECTIVES: Literature suggests that funding for pediatric clinical trials is inequitably awarded. Furthermore, although coronavirus disease 2019 (COVID-19) affected all hospitals, institutions with already limited resources were more severely impacted. We hypothesized that there would be difference in schools and hospitals that were able to participate in the initial round of pediatric COVID-19 clinical research. METHODS: We searched online databases for preregistered studies using the keywords “COVID-19,” “COVID,” “SARS-CoV-2,” “2019-nCov,” “2019 novel coronavirus,” and “severe acute respiratory syndrome coronavirus 2.” Search results were limited to studies enrolling participants from birth to 17 years, studies started in 2020, and studies originating in the United states. We calculated the proportion of institutions with active COVID-19 pediatric clinical studies in 2020 and compared institutional characteristics between institutions with and without at least one qualifying COVID-19 study, using rank-sum tests, χ2 tests, or Fisher’s exact tests, as appropriate. RESULTS: We identified 150 allopathic medical schools, 34 osteopathic medical schools, and 178 children’s hospitals meeting inclusion criteria. Among included institutions, 25% of medical schools and 20% children’s hospitals participated in 1 of the registered pediatric COVID-19 studies the year before the study period. Institutions that participated in pediatric COVID-19 studies had more publications, more National Institutes of Health funding, and more studies registered on Clinicaltrials.gov in 2019. CONCLUSIONS: Despite the pandemic affecting everyone, participation in early clinical research on the impact of COVID-19 in pediatric populations was concentrated in a few well-resourced institutions that were highly experienced in research.

Racial and Ethnic Variations in Mortality Associated with Common Pediatric Gastrointestinal Disorders in Children's Hospitals in the US

Background: The objective of this study is to determine the mortality, risk factors, and disease associations of eight common pediatric gastrointestinal (GI) disorders: cystic fibrosis (CF), cirrhosis, gastrointestinal bleeding (GIB), inflammatory bowel disease (IBD), liver failure (LF), liver transplant, acute pancreatitis, and short bowel syndrome (SBS). Methods: Diagnoses were found using the International Classification of Disease (ICD) codes from 2004 through 2020. We performed a retrospective cohort study using the Pediatric Health Information System (PHIS) database from 50 children’s hospitals in the US. We analyzed all encounters with ICD codes for these disorders, then determined the per-encounter mortality rate for each. We performed a mixed-effects logistic regression modeling hospital as a random effect, mortality as the dependent variable, and patient demographics and medical history as independent variables. We hypothesized that demographic factors such as Black race, Hispanic ethnicity, and markers of socioeconomic status would be associated with increased mortality. Results: The per-encounter mortality for each diagnosis was: cirrhosis (2.19%), CF (0.66%), GIB (4.22%), IBD (0.21%), LF (7.03%), liver transplant (0.37%), acute pancreatitis (2.23%), and SBS (1.13%). There was a higher (p<0.05) mortality for those of Asian race and mixed-race populations in GIB (OR 1.76 and 1.37, respectively) and acute pancreatitis (OR 1.94 and 1.34, respectively). For those of Black race, there was a higher mortality in liver transplant and liver failure (OR 1.31 and 1.65 respectively). Additionally, mortality was increased in Hispanic/Latino patients with CF, GIB, and SBS (OR 2.34, 1.39, and 1.41, respectively). Coincident cardiovascular, renal/urologic, and neurologic/neuromuscular abnormalities were also associated with a significant higher mortality. Conclusion: The degree of variation associated with race and ethnicity is unlikely to be accounted for by variation in clinical features, thus the impact of social determinants of health should be the focus of future study. Cirrhosis CF GIB IBD LF Liver Transplant Acute Pancreatitis SBS Mortality Rate 2.19% 0.66% 4.22% 0.21% 7.03% 0.37% 2.23% 1.13% Asian Race OR 1.10 3.77 1.76* 1.71 1.08 0.89 1.94* 1.35 Black Race OR 0.90 0.48 1.03 1.55 1.31* 1.65* 1.15 1.14 Mixed Race OR 1.16 1.12 1.37* 1.44 1.23 0.85 1.34* 1.16 Hispanic/Latino OR 1.13 2.34* 1.39* 1.53 1.16 1.65 1.13 1.41* *Significant OR numbers with an associated p<0.05

Quantifying Empiric Antibiotic Use in US Children’s Hospitals

OBJECTIVES Empirical broad-spectrum antibiotics are routinely administered for short durations to children with suspected bacteremia while awaiting blood culture results. Our aim for this study was to estimate the proportion of broad-spectrum antibiotic use accounted for by these “rule-outs.” METHODS The Pediatric Health Information System was used to identify children aged 3 months to 20 years hospitalized between July 2016 and June 2017 who received broad-spectrum antibiotics for suspected bacteremia. Using an electronic definition for a rule-out, we estimated the proportion of all broad-spectrum antibiotic days of therapy accounted for by this indication. Clinical and demographic characteristics, as well as antibiotic choice, are reported descriptively. RESULTS A total of 67 032 episodes of suspected bacteremia across 42 hospitals were identified. From these, 34 909 (52%) patients were classified as having received an antibiotic treatment course, and 32 123 patients (48%) underwent an antibiotic rule-out without a subsequent treatment course. Antibiotics prescribed for rule-outs accounted for 12% of all broad-spectrum antibiotic days of therapy. Third-generation cephalosporins and vancomycin were the most commonly prescribed antibiotics, and substantial hospital-level variation in vancomycin use was identified (range: 16%–58% of suspected bacteremia episodes). CONCLUSIONS Broad-spectrum intravenous antibiotic use for rule-out infections appears common across children’s hospitals, with substantial hospital-level variation in the use of vancomycin in particular. Antibiotic stewardship programs focused on intervening on antibiotics prescribed for longer durations may consider this novel opportunity to further standardize antibiotic regimens and reduce antibiotic exposure.