BACKGROUND AND OBJECTIVES The Nationwide Children’s Hospital’s (NCH) Pediatric Vital Signs (PVS) Initiative launched in May 2018 when the teenage birth rate in Franklin County was 20.9 per 1000 female adolescents in 2017. The aim of the PVS Preventing Unintended Teenage Pregnancy initiative was to leverage internal strengths and collaborations with community partners to accelerate the decline in the teenage birth rate in Franklin County using evidence-based programming, community engagement, and quality improvement science. METHODS We researched evidence-based interventions to reduce unintended teenage pregnancy and engaged community partners. NCH launched the Contraceptive Access Quality Improvement Collaborative (CAC) to increase the use of prescription contraceptives among female adolescent patients. The School Health Education Partnership focused on developing and promoting comprehensive sexual health education in community schools. Additional community collaborations and interventions activities supported the PVS aim for 5 years. RESULTS The teenage birth rate in Franklin County declined significantly between 2018 and 2022. The CAC achieved a statistically significant increase in the proportion of female adolescents seen at NCH who are prescribed contraceptives. Sexual health education programming has been implemented in 20 community middle schools since 2019. CONCLUSIONS An interdisciplinary team using a quality improvement framework, in collaboration with numerous community partners, engaged in diverse evidence-based programmatic activities to reduce the teenage birth rate in Franklin County, Ohio.

OBJECTIVE: To compare dental utilization and expenditures between children with and without behavioral health (BH) diagnoses in an accountable care organization. METHODS: This retrospective cohort study used enrollment and claims data of Medicaid-enrolled children in Ohio. Chil-dren with 7 years of continuous enrollment from 2013 to 2019 were included. We calculated 5 dental utilization outcomes: 1) Diagnostic only visits, 2) Preventive visits, 3) Treatment visits, 4) Treatment visits under general anesthesia (GA), and 5) Orthodontic visits. Total 7-year cumulative expenditures were calculated for each outcome. Multivariable logistic regression models were run for each outcome adjusting for demographics and medical comorbidities. RESULTS: Among 77,962 children, 23% had >= 1 BH diagno-sis. No utilization differences were noted between children with and without BH for diagnostic only visits, treatment vis-its, and orthodontic visits. BH status modified the likelihood of having a preventive visit and dental GA visits based on medi-cal comorbidity. For example, children with BH diagnoses had significantly lower odds of a preventive visit (eg, non-complex chronic comorbidity: odds ratio [OR] = 0.87, 95% confidence interval [CI]: 0.85-0.89), and significantly higher odds of a dental treatment under general anesthesia visit (eg, non -chronic comorbidity: OR = 3.69, 95% CI: 3.26-4.18). The total cumulative dental expenditures were $10.5M greater for children with BH. CONCLUSIONS: Children with BH diagnoses were signifi-cantly less likely to have preventive visits and more likely to have dental GA visits, which was expensive. Early identifica-tion and intervention could alter treatment approaches, improve care, reduce risk of harm, and achieve cost-savings within a pediatric accountable care organization.

Objectives: To evaluate child-level dental utilization and expenditure outcomes based on if and where children received fluoride varnish (FV) at quality improvement (QI) medical practices, at non-QI medical practices, at dental practices, or those who never received FV from any practice. Design: Retrospective claims-based analysis cohort study. Setting: Children with Medicaid insurance through an Ohio pediatric accountable care organization. Participants: Children aged 1 to 5 years with 1 or more well-child visits between 2015 and 2017. Intervention: FV receipt versus no FV. Among children who received FV, categorized if FV delivered by a QI-participating medical provider, a non-QI-participating medical provider, and a dental provider. Main Outcome Measure: Dental claims from 2014 to 2019 were collected for preventive dental visits, caries-related treatment visits, dental general anesthesia (GA) visit, and emergency department visit for a dental problem to examine utilization patterns, expenditures, and dental outcomes. Results: The QI group had a significantly higher incidence of preventive dental visits than the dental (incidence rate ratio [IRR] = 0.93; 95% confidence interval [CI], 0.91-0.96) or non-QI groups (IRR = 0.86; 95% CI, 0.84-0.88). Compared with the QI group, the non-QI (adjusted odds ratio [aOR] = 2.6; 95% CI, 2.4-2.9) and dental (aOR = 2.9; 95% CI, 2.6-3.3) groups were significantly more likely to have caries-related treatment visits. The dental group children were significantly more likely to have dental treatment under GA than the QI group (aOR = 5.3; 95% CI, 2.0-14.4). Conclusions: Children seen at QI practices appear to have an increased uptake of preventive dental services, which may explain the lower incidence of dental caries visits and GA treatment.

OBJECTIVES: Provision of reproductive health preventive services to adolescents is critical given their high rates of sexually transmitted infections and unintended pregnancies. Pediatricians are well positioned to provide these services but often face barriers. With this project, we aimed to build quality improvement (QI) capacity within pediatric practices to improve adherence to national guidelines for adolescent reproductive health preventive services. METHODS: In 2016, an accountable care organization overseeing health care delivery for low-income children in the Midwestern United States used practice facilitation, a proven approach to improve health care quality, to support pediatric practices in implementing reproductive health QI projects. Interested practices pursued projects aimed at providing (1) sexual risk reduction and contraceptive counseling (reproductive health assessments [RHAs]) or (2) etonogestrel implants. QI specialists helped practices build key driver diagrams and implement interventions. Outcome measures included the proportion of well-care visits with RHAs completed and number of etonogestrel insertions performed monthly. RESULTS: Between November 1, 2016, and December 31, 2019, 6 practices serving > 7000 adolescents pursued QI projects. Among practices focused on RHAs, the proportion of well-care visits with completed RHAs per month increased from 0% to 65.8% (P<.001) within 18 months. Among practices focused on etonogestrel implant insertions, overall insertions permonth increased from 0 to 8.5 (P<.001). CONCLUSIONS: Practice facilitation is an effective way to increase adherence to national guidelines for adolescent reproductive health preventive services within primary care practices. Success was driven by practice-specific customization of interventions and ongoing, hands-on support.

Purpose of review Direct-acting antiviral (DAA) regimens targeting hepatitis C virus (HCV) are now approved for young children. This review examines recent DAA experience in children, current treatment recommendations and challenges, and potential treatment-as-prevention strategies. Recent findings In 2021, the US FDA extended approval of two pan-genotypic DAA regimens, glecaprevir/pibrentasvir and sofosbuvir/velpatasvir, to children as young as age 3 years based on high success rates and reassuring safety profiles in registry trials. Similar performance has been replicated with real-world DAA use in thousands of adolescents and in limited reports of children with high-risk conditions, including cirrhosis, cancer, thalassemia and HIV-coinfection. Treatment without delay is now recommended in the USA for viremic children aged 3 years and up to prevent disease progression and future spread. To date, treatment expansion is limited by high rates of undiagnosed paediatric infection. Universal prenatal screening will aid identification of perinatally exposed newborns, but new strategies are needed to boost testing of exposed infants and at-risk adolescents. Postpartum treatment programmes can prevent subsequent vertical transmission but are hampered by low rates of linkage to care and treatment completion. These challenges may be avoided by DAA use in pregnancy, and this warrants continued study. Summary Paediatric HCV is now readily curable. Substantial clinical and public health effort is required to ensure widespread uptake of this therapeutic breakthrough.

OBJECTIVE:To examine healthcare utilisation for all firearm-related injuries among publicly insured children.METHODS:A retrospective analysis of firearm injury medical claims among paediatric (<21 years) Medicaid beneficiaries in Ohio from 2010 to 2018. Factors associated with unintentional and intentional firearm injury were explored using multivariable logistic regression. Average annual patient healthcare costs were determined in 2019 US$.RESULTS:There were 1061 firearm injury-related claims (853 (80%) unintentional; 154 (15%) intentional; 54 (5%) unknown) occurring in 663 children over 2 736 517 available person-years. From 2010 to 2018, yearly total firearm claims rose from 19.7 to 31.3 per 100 000 persons (p=0.033). Urban children experienced a non-significant increase in firearm claims rate over time (26.1 vs 35.0/100 000; p=0.066) while the claims rate nearly tripled among those in rural areas (8.4 vs 24.0/100 000; p=0.012). Younger age, females and rural residence were associated with reduced odds of injury claims. The average annual costs for emergency department and inpatient visits, respectively, were $260 and $5735.CONCLUSION:Risk and type of firearm injury claims among low-income children in Ohio varies by age, sex and residence. Prevention programmes should be tailored based on these demographics.

Objective To evaluate whether quality improvement (QI) capacity-building in affiliated primary care practices could increase well care visit uptake. Study design Partners For Kids (PFK) is an accountable care organization caring for pediatric Medicaid beneficiaries in Ohio. PFK QI specialists recruited practices to develop QI projects around increasing well care visit rates (proportion of eligible children with well care visits during calendar year) for children aged 3-6 years and adolescents. The QI specialists supported practice teams in implementing interventions and collecting data through monthly or bimonthly practice visits. Results Ten practices, serving more than 26 000 children, participated in QI projects for a median of 8.5 months (IQR 5.3-17.6). Well care visit rates in the QI-engaged practices significantly improved from 2016 to 2018 (P < .001 for both age groups). Over time, well care visit rates for 3- to 6-year-old children increased by 11.8% (95% CI 5.4%-18.2%) in QI-engaged practices, compared with 4.1% (95% CI 0.1%-7.4%) in non-engaged practices (P = .233). For adolescents, well care visit rates increased 14.3% (95% CI -2.6% to 31.2%) compared with 5.4% (95% CI 1.8%-9.0%) in QI-engaged vs non-engaged practices over the same period (P = .215). Although not statistically significant, QI-engaged practices had greater magnitudes of rate increases for both age groups. Conclusions Through practice facilitation, PFK helped a diverse group of community practices substantially improve preventive visit uptake over time. QI programs in primary care can reach patients early to promote preventive services that potentially avoid costly downstream care.

BACKGROUND:Most US children with perinatal hepatitis C virus (HCV) exposure fail to receive the recommended anti-HCV antibody test at age ≥18 months. Earlier testing for viral RNA might facilitate increased screening, but sensitivity of this approach has not been established. We hypothesized that modern HCV-RNA RT-PCR platforms would adequately detect infected infants. METHODS:Nationwide Children's Hospital electronic health records from 1/1/2008 to 30/6/2018 were reviewed to identify perinatally exposed infants tested by HCV-RNA RT-PCR at age 2-6 months. Diagnostic performance was determined using a composite case definition: (1) infected children had positive repeat HCV-RNA testing or positive anti-HCV at age ≥24 months; (2) uninfected children lacked these criteria and had negative anti-HCV at age ≥18 months. RESULTS:770 perinatally exposed infants underwent HCV-RNA testing at age 2-6 months. Of these, 28 (3.6%) tested positive; viremia was confirmed in all who underwent repeat testing (n = 27). Among 742 infants with negative HCV-RNA results, 226 received follow-up anti-HCV testing at age ≥18 months, of whom 223 tested negative. Three children had low-positive anti-HCV results at age 18-24 months that were negative upon retesting after age 24 months, possibly indicating waning maternal antibodies. Using the composite case definitions, early HCV-RNA screening demonstrated sensitivity of 100% (87.5-100%, Wilson-Brown 95% CI) and specificity of 100% (98.3-100%). CONCLUSIONS:Modern HCV-RNA RT-PCR assays have excellent sensitivity for early diagnosis of perinatally acquired infection and could aid HCV surveillance given the substantial loss to follow-up at ≥18 months of age.

Introduction: Despite improvements in pediatric heart transplant outcomes, respiratory syncytial virus (RSV) and vaccine preventable infections (R/VPI) are a major cause of morbidity and hospital resource use. The frequency and risk factors for hospitalizations due to R/VPI in heart transplant recipients are unknown. Methods: Patients ≤18 years who underwent heart transplantation at hospitals contributing to the Pediatric Health Information System database from 9/2003 to 12/2018 were identified. The transplant hospitalization and subsequent hospitalizations for R/VPI through 12/2018 were analyzed. Risk factors for R/VPI hospitalizations were evaluated using negative regression binomial models adjusted for potential demographic and clinical confounders. Total hospital costs were determined adjusted for 2018 US $. Results: Of 3,815 transplant recipients, 681 (17.9%) had a R/VPI hospitalization during 23,746 available person-years of follow-up after transplant. There were 984 R/VPIs diagnosed during 951 hospitalizations, and 440 (44.7%) occurred in the first year after transplant (Figure). The most common causes were RSV (n=380; 38.6%), influenza (n=265; 26.9%), and pneumococcus (n=105; 10.7%). In adjusted analyses, there was an increased risk of R/VPI hospitalization in patients requiring mechanical circulatory support prior to transplant, those who received induction with ≥ 2 immunosuppressive agents, and patients <2 years old. The median length of stay for a R/VPI hospitalization was 4 days (interquartile range [IQR]: 2-8 days) with a median total cost of $11,081 (IQR: $6,215 - $24,322). Conclusions: Hospitalization for R/VPIs occurred frequently following pediatric heart transplantation and were associated with significant cost. Potential strategies to minimize R/VPI could include expanding vaccine use through accelerated immunization schedules in younger patients and routine monitoring of immunogenicity after vaccination.

One dose of the measles-mumps-rubella (MMR) vaccine confers ≥93% protection against measles.1 In 2017, nearly 10% of children aged 19 to 35 months in the United States had not received the first dose of the MMR vaccine.2 The vaccination rate was lower among those who were uninsured or Medicaid enrolled compared with those with private insurance and among Black children compared with white children.2 In May 2020, the Centers for Disease Control and Prevention reported a precipitous drop in vaccination within one state after the severe acute respiratory syndrome coronavirus 2 pandemic began.3 Lower MMR vaccination rates raise serious concerns about a possible measles resurgence3 in the United States because of the high level of herd immunity needed to prevent community transmission.1 We evaluated changes in measles vaccination rates from the pandemic start when clinic access and attendance decreased to the period in which return for clinical care was encouraged.The Nationwide Children’s Hospital pediatric primary care network includes 12 clinic sites in Columbus, Ohio, providing care for >90 000 children and adolescents, most of whom are Medicaid enrolled and belong to a racial or ethnic minority group. The primary study outcome was the proportion with MMR vaccination by age 16 months from March 2017 to August 2020. We considered the initial pandemic period to be those full months with restricted clinic access (April to May 2020) during which telemedicine was encouraged for many visit types but in-person preventive visits for children ≤2 years were still scheduled, and we considered the reopening period to be when access normalized and scheduling outreach by mail, telephone, and text was used to re-engage families (June to August 2020). The χ2 test or Fisher’s exact test was used for bivariate analysis. The confidence interval around the proportion vaccinated was adjusted for clustering by clinic site with sandwich estimators. Because of previously recognized disparities and the differential impact of coronavirus disease 2019 (COVID-19),4 we evaluated the association of vaccination with insurance status at the child’s most recent visit and race and/or ethnicity using logistic regression with adjustment for clustering by clinic site. Stata 16 (Stata Corp, College Station, TX) was used for all analyses. The Nationwide Children’s Hospital Institutional Review Board approved this study.From March 2017 to March 2020, the average proportion of 16-month-old children with MMR vaccination was 72.0%, which decreased to 66.8% in April to May 2020 (P < .001) and then to 62.4% (P = .02) from June to August 2020 (Table 1, Fig 1). In Table 1, the population demographic characteristics, the proportion who were vaccinated, and the adjusted odds of vaccination are listed. Patients without insurance were less likely to be vaccinated than those with private insurance or enrolled in Medicaid. Compared with patients who were Hispanic or Asian American, white and Black patients were less likely to be vaccinated (Table 1; P < .001). Although there was a difference in vaccination between white and Black patients in the unadjusted analyses (Table 1; P = .001), there was no difference after adjustment for insurance status and time period (P = .31). There was no significant interaction between race and/or ethnicity and insurance status or time period in the likelihood of vaccination.Regardless of time period, those with a preventive care visit after 12 months of age were more likely to be vaccinated (91.2% vs 8.8%; P < .001). The proportion of children with such visits decreased during the postpandemic period (Fig 1; 76.2% vs 70.9%; P < .001). For those without any preventive care visits after age 12 months, the proportion vaccinated decreased across the time periods (prepandemic: 9.7%; initial: 6.3%; reopening: 2.5%; P = .01).Although preventive visits for children aged ≤2 years have always been offered in the clinics, and by June outreach efforts were implemented to have patients return to the clinic for all health care needs, the pandemic-related decline in MMR vaccination has persisted, as has the decline in preventive care visits. The fourfold decrease in vaccination outside of preventive visits is an important contributor to the drop in the MMR vaccination rate. Although it is possible that we did not capture all vaccinations administered to patients elsewhere during the initial pandemic and reopening time periods, the likelihood is low because the local health department stopped offering vaccinations at the start of the pandemic. Because we focused on an urban sample primarily composed of publicly insured minority children in this study, these findings may not generalize to other clinic types and communities.Given the baseline low vaccination rates even before the pandemic and the subsequent decline, we face a critical need to improve timely vaccination and provide catch-up opportunities in the area with the highest incidence of COVID-19 in Ohio.5 To address this, we are implementing new community-based vaccination approaches funded in partnership with our institution (eg, pop-up vaccine clinics, mobile clinics, school-based clinics with increased capacity owing to remote learning), which offer an alternative for families hesitant to visit our clinics because of COVID-19 concerns. However, by separating vaccination from the full range of preventive services, we recognize that opportunities to promote child health and development, which have great importance because of increased family stress and social needs at this time, might be missed. We believe that it is critical to develop innovative approaches to have families return for preventive care.Although we did not find a disparity between white and Black children in MMR vaccination, it is the falling absolute rate of vaccination that puts everyone at risk. We are now working with community members to understand why Asian American and Hispanic families were more likely to be vaccinated, which might lead to new vaccine promotion strategies and vaccination coverage overall. The lower rate among uninsured patients emphasizes the importance of our ongoing work to help families enroll in insurance.Uptake of MMR vaccination is not only critical for protecting the broader community against other infectious outbreaks but also a bellwether of preventive services overall. In this study, we focused on the first MMR vaccination because we hypothesized that any changes in vaccination rates due to pandemic-related closures likely would be identified earliest among young children who require frequent preventive visits. It is too soon to evaluate whether there has been a decrease related to the second MMR vaccination, which is recommended between 4 and 6 years of age. Despite our efforts to have families return for preventive care, we need novel strategies to ensure the delivery of comprehensive preventive services, including catch-up vaccination efforts that might need to extend beyond the end of the pandemic to protect our community from vaccine-preventable outbreaks.

Objective To understand current donor heart allocation practices for pediatric transplantation. Background Despite high waitlist mortality rates among pediatric patients awaiting transplant, a substantial proportion of donor hearts go unused. Analysis of UNOS match run data may identify opportunities to optimize organ utilization. Methods Using UNOS/OPTN data, we evaluated all match runs for pediatric (<18 years) donor hearts from 1/1/2006 to 3/31/2017. We assessed final disposition of donor hearts, reasons for donor refusal, and other match run characteristics. Variation in total offers made per organ, and refusal rates by OPOs were also evaluated. Results Of 7585 pediatric potential donor hearts, 2226 (29.3%) were refused. Hearts accepted underwent a median of 2 offers (IQR: 1-5), compared to 11 (IQR: 5-24) for refused donor hearts. Organ refusal rates decreased from 36.9% in 2006-2009 to 22.3% in 2014-2017 (P < .001). Reasons for refusal included quality (80.9%), size mismatch (57.5%), and known/suspected crossmatch positivity (39.1%). Among 1800 hearts deemed "poor quality" by >= 1 transplant program, less than half (46.6%) were coded "poor quality" by multiple refusing programs. Organ refusal rates ranged from 13.5% to 83.3% across OPOs, and there was no correlation between refusal rates and median number of offers made by the OPO. Conclusion Although more organs are being used over time, 1 in 5 available pediatric donor hearts are still discarded. The lack of donor evaluation consensus and wide variability in donor refusal rates indicates a need for standardization of donor assessment and match run processes across OPOs.

Purpose Using current allocation schemes, high-risk pediatric donor hearts are under-utilized. This study examined how recipient illness severity may influence acceptance of risk-stratified donor organs and the impact of this paradigm on graft survival/mortality. Methods The UNOS database was queried for pediatric (<18yrs) heart transplants performed from 1999-2017 with recipients classified by illness severity. Severely ill recipients had 1) ECMO or ventilator at transplant; or 2) eGFR <30 ml/min/1.73m2 or dialysis. Non-hospitalized recipients with eGFR >60 and bilirubin < 2mg/dl were deemed mildly ill; all others were moderately ill. Using the Pediatric Heart-Donor Assessment Tool (Zafar et al, JHLT 2018), which incorporates ischemic time, cause of death, height ratio, cardiac & renal function, donor organs were classified as low, medium or high risk. Kaplan-Meier curves of 1- and 5-year graft survival, adjusted for age, race & congenital heart disease, were generated for varying levels of donor risk, stratified by recipient illness severity. Results Severely ill patients were more likely to receive medium or high risk organs (67.2%) than moderately (56.2%) or mildly ill (51.6%) patients (both p<0.001). In moderately and severely ill patients, use of high risk donor organs was associated with increased rates of both 1- and 5-year graft failure/mortality. Among mildly ill patients, rates of 1- and 5-year survival without graft failure did not differ significantly across donor risk groups (Figure 1). Conclusion Illness severity of pediatric heart recipients influences the impact that donor organ risk has on graft failure/mortality. While very ill patients had worse outcomes after transplant with higher risk organs, post-transplant outcomes were comparable among less ill patients, regardless of donor risk. This suggests that higher risk organs may be preferentially allocated to less ill patients, without compromising outcomes, thereby reducing donor waste and overall waitlist mortality. Using current allocation schemes, high-risk pediatric donor hearts are under-utilized. This study examined how recipient illness severity may influence acceptance of risk-stratified donor organs and the impact of this paradigm on graft survival/mortality. The UNOS database was queried for pediatric (<18yrs) heart transplants performed from 1999-2017 with recipients classified by illness severity. Severely ill recipients had 1) ECMO or ventilator at transplant; or 2) eGFR <30 ml/min/1.73m2 or dialysis. Non-hospitalized recipients with eGFR >60 and bilirubin < 2mg/dl were deemed mildly ill; all others were moderately ill. Using the Pediatric Heart-Donor Assessment Tool (Zafar et al, JHLT 2018), which incorporates ischemic time, cause of death, height ratio, cardiac & renal function, donor organs were classified as low, medium or high risk. Kaplan-Meier curves of 1- and 5-year graft survival, adjusted for age, race & congenital heart disease, were generated for varying levels of donor risk, stratified by recipient illness severity. Severely ill patients were more likely to receive medium or high risk organs (67.2%) than moderately (56.2%) or mildly ill (51.6%) patients (both p<0.001). In moderately and severely ill patients, use of high risk donor organs was associated with increased rates of both 1- and 5-year graft failure/mortality. Among mildly ill patients, rates of 1- and 5-year survival without graft failure did not differ significantly across donor risk groups (Figure 1). Illness severity of pediatric heart recipients influences the impact that donor organ risk has on graft failure/mortality. While very ill patients had worse outcomes after transplant with higher risk organs, post-transplant outcomes were comparable among less ill patients, regardless of donor risk. This suggests that higher risk organs may be preferentially allocated to less ill patients, without compromising outcomes, thereby reducing donor waste and overall waitlist mortality.

OBJECTIVES:Quality improvement (QI) methodologies are not widely implemented in primary care practices. As an accountable care organization serving pediatric Medicaid recipients in Ohio, Partners For Kids (PFK) sought to build QI capacity in affiliated primary care practices to improve organizational performance on key quality measures.METHODS:A team of QI specialists developed a comprehensive training program focused on pediatric QI initiatives. From 2014 to 2017, community-based, primary care practices affiliated with PFK were recruited to participate in QI. The primary outcome, assessed yearly, was the proportion of eligible PFK patients accessing care at a practice with ≥1 active QI project. The proportion of QI projects that demonstrated moderate improvement, defined as the implementation of ≥1 intervention and observed improvement in process measures, within 12 months of initiation was also calculated for 2017.RESULTS:Over the study period, the PFK QI team supported 72 projects in 33 primary care practices throughout central and southeast Ohio. In 2017, 26 practices were engaged in ≥1 active QI project, reaching 26% of all eligible PFK patients. Of the 21 projects active as of January 2017, 11 (52%) showed moderate improvement within 12 months.CONCLUSIONS:The PFK QI team successfully supported QI capacity building in primary care practices throughout Ohio using a systematic approach to recruitment, training, and QI resource support. New, multilevel interventions are needed to promote the uptake of preventive services among patients.

Background: Changes in orthotopic heart transplantation (OHT) practices over time have been difficult to assess due to reliance on voluntary registry data with limited patient granularity. Here, we use the Pediatric Health Information System database (PHIS) to study the clinical management of OHT recipients during the initial transplant admission. Methods: A retrospective cohort studywas performedof all OHT recipients <19 years old in PHIS from 2003 to 2017. Using administrative data collected from the initial transplant admission, we determined length of stay, duration of ICU care, …

Accountable care organizations (ACOs) have emerged as an effective healthcare delivery model for managing quality and cost at a population level. Within ACOs, pharmacists are critical for the delivery of high-value health care, offering patients and health care providers medication-related training, resources, and guidance that can improve quality of care at lower costs. Partners For Kids (PFK), one of the oldest and largest pediatric ACOs in the country, has successfully leveraged pharmacists to provide population health management and medication management to promote health outcomes for individual patients and the overall population it serves. This review explores how the inclusion of pharmacists in the development and execution of various quality improvement initiatives within PFK has positively impacted outcomes for patients while also lowering overall spend. A catalog of interventions is provided to offer various ways that pharmacists can intersect as providers in the triad of patient/family, payor, and provider. By providing enhanced training and education, on-site guidance, medication management, and population-level data analysis, pharmacists are able to identify and improve inefficiencies in care. Moving forward, ongoing engagement of pharmacists in health care operations will be a necessary feature to maximize health care value.

BACKGROUNDHepatitis C virus (HCV) infection is under-recognized among US adults and children. Prenatal HCV screening may help close the diagnosis gap among women while also identifying at-risk infants. Current surveillance efforts for maternal HCV rely primarily on birth certificate data. We sought a more accurate assessment of HCV prevalence among pregnant women in Ohio by combining existing public health surveillance data.METHODSVital Statistics (VS) birth certificate data and Ohio Disease Reporting System (ODRS) HCV case data, both available through the Ohio Department of Health, were linked to determine rates of past or present HCV infection among women giving birth from 2012 to 2015 in Ohio, overall and by county. Among women with available test results, the proportion with present HCV infection indicated by detectable viraemia during pregnancy was calculated.RESULTSBirth certificate data identified 4695 deliveries to women with past/present HCV infection during the study period. Linkage to ODRS revealed an additional 1778 deliveries to women with past/present infection, including 355 with confirmed viraemia during pregnancy. The prevalence of past/present HCV among pregnant women in Ohio rose from 0.82% in 2012 to 1.54% in 2015.CONCLUSIONSMaternal HCV infection is under-recognized and increasing in prevalence. Current case identification processes are inadequate in pregnancy, even among women with prior positive HCV testing. Alternative approaches, including enhanced risk factor-based screening or universal prenatal screening in high prevalence settings, are needed to improve rates of HCV recognition among reproductive-aged women and newborns at risk of vertical transmission.

INTRODUCTIONNeonates with hypoplastic left heart syndrome (HLHS) are at increased risk for necrotizing enterocolitis (NEC). Initial hospital outcomes are well described, but minimal midterm data exist. Goal of this study was to compare outcomes of HLHS infants with NEC (HLHS-NEC) to HLHS without NEC (HLHS-nNEC) during the interstage period.METHODSData were reviewed from 55 centers using the NPC-QIC database. Case-control study with one HLHS-NEC matched to HLHS-nNEC neonates in a 1:3 ratio based on institutional site, type of surgical repair, and gestational age ±1 week was performed. Baseline demographics as well as outcome data were recorded. The t tests or chi-square tests were performed as appropriate.RESULTSThere were 57 neonates in the HLHS-NEC (14 Norwood-BT, 37 Norwood-RVPA, and 6 hybrid) and 171 neonates in the HLHS-nNEC group. There were significant differences between the HLHS-NEC versus HLHS-nNEC for presence of atrioventricular valve regurgitation (7% vs 2%), use of extracorporeal membrane oxygenation (11% vs 2%), hospital stay (60.4 ± 30.0 vs 36.3 ± 33.6 days), Z-score weight at discharge (-2.1 vs -1.6), incidence of no oral intake (33% vs 14%), and use of formula only nutrition at discharge (61% vs 29%), respectively. There were no significant differences between groups in readmission rates due to adverse gastrointestinal events, use of gastrointestinal medications, interstage deaths, or Z-score weight at time of second surgery. HLHS-NEC continued to be more likely to be entirely tube dependent for enteral intake at time prior to the second procedure (39% vs 15%).CONCLUSIONSDespite similar baseline characteristics, HLHS-NEC infants had significant differences in hospital course compared with HLHS-nNEC neonates. In addition, HLHS-NEC infants were less likely to be fed orally during the entire interstage period. Future studies are needed minimize NEC in this high risk population to possibly improve oral feeds.

Pediatric patients awaiting heart transplant face high mortality rates due to donor organ shortages, including non‐use of marginal donor hearts. We examined national trends in pediatric marginal donor heart use over time. UNOS data were queried for heart donors <18 years from 2005 to 2014. The proportion of donor hearts considered marginal was determined using previously cited marginal characteristics: left ventricular ejection fraction (LVEF) <50%, use of ≥2 inotropes, cerebrovascular death, CDC high‐risk status, and eGFR < 30 mL/min/1.73 m2. Disposition of donor hearts was determined and stratified by marginal donor status. Of 6778 pediatric hearts offered from 2005 to 2014, 2373 (35.0%) were considered marginal. Non‐use of marginal donor hearts was significantly higher than that of donor hearts without any marginal characteristics (59.5% vs 20.3%, P < .001). In particular, LVEF < 50% and donor inotropes were associated with high rates of organ non‐use among pediatric donors. Yet, non‐use of marginal donor organs decreased from 67% to 48% from 2005 to 2014 (P < .001). Although the proportion of pediatric donor hearts used for pediatric patients has increased, more than half of donor hearts are declined for use in pediatric recipients due, in part, to perceived marginal status.

Background:Despite the availability of new direct-acting antiviral (DAA) regimens, changes in DAA reimbursement criteria, and a public health focus on hepatitis C virus (HCV) elimination, it remains unclear if public and private insurers have increased access to these therapies over time. We evaluated changes in the incidence of absolute denial of DAA therapy over time and by insurance type. Methods:We conducted a prospective cohort study among patients who had a DAA prescription submitted from January 2016 to April 2017 to Diplomat Pharmacy, Inc., which provides HCV pharmacy services across the United States. The main outcome was absolute denial of DAA prescription, defined as lack of fill approval by the insurer. We calculated the incidence of absolute denial, overall and by insurance type (Medicaid, Medicare, commercial), for the 16-month study period and each quarter. Results:Among 9025 patients from 45 states prescribed a DAA regimen (4702 covered by Medicaid, 1821 Medicare, 2502 commercial insurance), 3200 (35.5%; 95% confidence interval, 34.5%-36.5%) were absolutely denied treatment. Absolute denial was more common among patients covered by commercial insurance (52.4%) than Medicaid (34.5%, P < .001) or Medicare (14.7%, P < .001). The incidence of absolute denial increased across each quarter of the study period, overall (27.7% in first quarter to 43.8% in last quarter; test for trend, P < .001) and for each insurance type (test for trend, P < .001 for each type). Conclusions:Despite the availability of new DAA regimens and changes in restrictions of these therapies, absolute denials of DAA regimens by insurers have remained high and increased over time, regardless of insurance type.

Many children born to HCV-infected mothers in the U.S. never receive recommended anti-HCV antibody (Ab) screening at age ≥ 18 months. Earlier testing by HCV-RNA PCR might facilitate increased screening, though prior studies using older PCR assays reported unacceptably low sensitivity of one-time PCR testing in infants. We hypothesized that testing at age 2–6 months using modern blood HCV-RNA PCR platforms with enhanced analytical sensitivity and reliability will adequately detect infected infants. Medical records of vertically exposed infants tested for HCV-RNA at age 2–6 months at Nationwide Children’s Hospital from January 1, 2008 to December 31, 2017 were reviewed. HCV-RNA tests included qualitative (in-house) and quantitative (ARUP reference lab) Cobas Taqman RT-PCR assays (Roche) with lower limits of detection of 1.2–1.9 log10 IU/mL. Diagnostic performance of early PCR screening was determined using a composite gold standard: (1) infected children had ≥ 2 positive PCRs or persistently positive Ab after age 24 months; (2) uninfected children lacked these criteria and required documentation of a negative Ab at a point after age 18 months. During the study period, 639 vertically exposed infants underwent HCV-RNA testing at age 2–6 months. Of these, 24 (3.8%) tested positive, consistent with prior estimates of the vertical transmission rate. Blood HCV-RNA levels were high at screening (median 6.7 log10 IU/mL, range 5.2–7.8 log10 IU/mL), and confirmatory PCR tests were positive in all who had repeat testing (n = 22). Among 615 infants with negative PCR screening, 444 had reached age ≥ 18 months, of whom 144 had undergone Ab testing. Ab tests were negative in 142, while two children had low positive Ab results at 18 months. In both cases, repeat PCR and repeat Ab after age 24 months were negative, suggesting waning maternal Ab rather than true infection. Using the composite gold standard there were 22 true positive, 0 false-positive, 144 true negative, and 0 false negative cases, yielding a sensitivity of 100% (95% CI: 85–100% [Wilson-Brown]). These findings demonstrate that modern blood HCV-RNA PCR assays have excellent sensitivity for detecting vertically infected infants as early as 2–6 months of age and may improve HCV surveillance given the substantial number of children lost to follow-up prior to 18 months Ab screening. All authors: No reported disclosures.