BACKGROUND/OBJECTIVE:Prior disparity research has focused on evaluating patient outcomes in freestanding children's hospitals, rather than identifying potential drivers of these disparities. Our objective was to evaluate drivers of disparities in respiratory illness care quality and outcomes in a national sample of general hospitals. METHODS:This retrospective study used pretrial data from hospitals in the SIP trial (Simultaneously Implementing Pathways for Improving Asthma, Pneumonia, and Bronchiolitis Care for Hospitalized Children, NCT05206695). Patients were eligible if they had a primary diagnosis of asthma, pneumonia, or bronchiolitis and were admitted during 3 winter periods (2019-2022). We evaluated quality measures/adherence to evidence-based practices and patient outcomes (length of stay, intensive care unit [ICU] transfer, and hospital readmission/emergency department [ED] revisit within 30 days). Multilevel regression models were used to evaluate disparities by race and ethnicity, primary insurance, and preferred language. RESULTS:A total of 3188 admissions from 33 hospitals were analyzed. Quality measure adherence was 30% to 89%. Children with asthma on public insurance were more likely to receive recommended discharge prescriptions of inhaled corticosteroids than those on private insurance (77% vs 70%; odds ratio [OR], 1.87 [95% CI, 1. 12-3.12]). Children with public insurance admitted for asthma had higher risk of ICU transfer (adjusted OR [AOR], 1.93 [95% CI, 1.01-3.72]) and 30-day readmissions/ED revisits (AOR, 2.72 [95% CI, 1.37-5.39]). Hispanic children admitted for asthma had higher risk of 30-day readmissions/ED revisits compared with white children (AOR, 2.37 [95% CI, 1.08-5.22]). CONCLUSIONS:In this national analysis of children admitted to general hospitals, we found disparities in outcomes for children with asthma who were on public insurance or Hispanic.

BACKGROUND AND OBJECTIVE General hospitals care for more than 70% of hospitalized children nationally but face challenges in pediatric quality improvement (QI). Feasibility and organizational readiness to change assessments can help inform effective QI. Our objective was to assess readiness to implement pediatric QI interventions among a broad sample of general hospitals participating in the Simultaneously Implementing Pathways for Improving Asthma, Pneumonia, and Bronchiolitis Care for Hospitalized Children (SIP) study. METHODS We conducted a mixed-methods study. Data were collected via electronic surveys and qualitative interviews. Participants included multidisciplinary inpatient pediatric clinicians and QI leaders. Surveys used validated tools, including the Organizational Readiness to Implement Change (ORIC) and Feasibility of Intervention Measure (FIM). Interview guides developed using an implementation framework explored feasibility of implementing evidence-based practices. We analyzed data using descriptive statistics and thematic analysis. RESULTS A total of 424 participants from 15 hospitals were approached, and 186 (44%) completed the survey. ORIC and FIM scores were scaled 1 to 5, with higher scores indicating agreement. Response results did not differ based on clinician type or experience. Clinicians at community hospitals with pediatric beds reported greater readiness than nested children’s hospitals (median ORIC 4.4 vs 4.0, P = 0.02). Interviewees’ (n = 21) anticipated feasibility challenges included aligning practices across hospital care settings and obtaining information technology support for electronic medical record changes. CONCLUSIONS In this mixed-methods study, we found high but variable readiness for pediatric QI and identified specific threats to feasibility. We also illustrated how such assessments can be used to support pediatric QI efforts in general hospitals.

Background Craniosynostosis is treated with endoscopic, open, and/or distraction surgical techniques. We assessed institutional variation in the use these techniques for craniosynostosis and compared hospital resource use. Methods Retrospective analysis of 5249 infants age <18 months old undergoing surgical procedures for all types of craniosynostosis in 2016–2020 in 39 freestanding children's hospitals in the Pediatric Health Information System (PHIS) database. Endoscopic vs. open cranial vault surgery (with and without distraction osteogenesis) was identified using ICD-10-CM codes. Inpatient cost and length of stay (LOS) were compared by surgery type with Wilcoxon Rank Sum. Results There was significant (p < .001) variation in the percentage of infants who underwent endoscopic repair across hospitals [median 23.6% (interquartile range (IQR): 7.6%–37.5%), range: 0% to 80.4%] and across regions [range: 22.1% (southeast) to 42.5% (northeast)]. For endoscopic procedures, median LOS and inpatient cost were lower (p < .001) without vs. with distraction [1 day (IQR 1–1) vs. 2 days (IQR 2–2); $14,617 (IQR 11,823–22178) vs. $33,599 (IQR 22,800–38,619)]. For open interventions, median LOS and inpatient cost were also lower (p < .001) without vs. with distraction [3 days (IQR 2–4) vs. 5 days (IQR 4–6) and $37,251 (IQR 27,114–50.320) vs. $62,247 (IQR 42,124–91,620)]. Conclusions Substantial variation in the surgical approach for craniosynostosis exists across hospitals and regions. Endoscopic repair without distraction had the lowest hospital resource use, while open repair with distraction had the highest hospital resource. Subsequent analysis of short- and long-term outcomes as well as patient-and-family costs is necessary to assess the true cost-effectiveness of each approach.

Purpose: Chlamydia trachomatis (CT) and Neisseria gonorrhea (GC) infections are common among 15- to 24 -year -olds, with Black and Hispanic youth disproportionately affected. Understanding where youth receive CT/GC testing is necessary to address disparities in CT/GC care. Our objective was to identify if differences exist in CT/GC testing locations by race and ethnicity. Methods: We used 2019 MarketScan Medicaid data to examine CT/GC testing location by youth race and ethnicity. Results: There were 418,623 CT/GC tests during the study period. Tests were most frequently ordered at medical offices for all races and ethnicities, although less frequently for Black (37.6%) and Hispanic (37.3%) than for White youth (49.3%). Black youth were frequently tested in emergency departments (19.6%), while Hispanic youth were frequently tested in Federally Qualified Health Centers (19.0%). Discussion: We found significant racial and ethnic disparities in the location of CT/GC testing among Medicaid -insured -youth; these findings should be used to guide strategies that address inequities in CT/GC care. (c) 2023 Society for Adolescent Health and Medicine. All rights reserved.

Abstract Background Little is known about healthcare providers’ (HCPs) contraceptive views for adolescents in Haiti, who experience high rates of unintended pregnancy. We sought to describe HCPs’ perspectives on barriers and facilitators to contraceptive care delivery in rural Haiti. Methods We conducted a cross-sectional survey and qualitative interviews with HCPs in two rural communities in Haiti from 08/2021–03/2022. We assessed demographics, clinical practice behaviors and explored contraception perspectives according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control (e.g., people’s perceptions of their ability to perform a given behavior, barriers and facilitators of a behavior).15–17 We used descriptive statistics to report proportions and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through thematic inductive coding and team debriefing. Results Among 58 respondents, 90% (n = 52) were female and 53% (n = 31) were nurses. Most reported always (n = 16, 28%) or very often (n = 21, 36%) obtaining a sexual history for adolescents. A majority agreed/strongly agreed that clinicians should discuss pregnancy prevention (n = 45, 78%), high-risk sexual behaviors (n = 40, 69%), and should prescribe contraception (n = 41, 71%) to adolescents. The most frequently cited provider-level barriers (i.e., significant or somewhat of a barrier) included insufficient contraception knowledge (n = 44, 77%) and time (n = 37, 64%). HCPs were concerned about barriers at the patient-level (e.g. adolescents’ fear of parental notification [n = 37, 64%], adolescents will give inaccurate information about sexual behaviors [n = 25, 43%]) and system-level (e.g. resistance to providing care from administration [n = 33, 57%]). In interviews (n = 17), HCPs generally supported contraception care for adolescents. Many HCPs echoed our quantitative findings on concerns about privacy and confidentiality. HCPs reported concerns about lack of contraception education leading to misconceptions, and community and parental judgement. HCPs expressed interest in further contraception training and resources and noted the importance of providing youth-friendly contraceptive care. Conclusions While HCPs support contraceptive care, we identified actionable barriers to improve care for adolescents in rural Haiti. Future efforts should include increasing HCP knowledge and training, community and parent coalition building to increase contraception support and offering youth-friendly contraceptive care to offset risk for related adverse health outcomes in adolescents in rural Haiti.

Purpose: This study evaluates recent trends in substance-related visits among youth visiting children 's hospitals. Methods: We conducted a cross-sectional study of substance-related visits to pediatric hospitals within the Pediatric Health Information System database of youth aged 12-21 years from 2016 through 2021. Substance-related visits were de fined as acute visits for International Classi fication of Diseases, 10th Revision Clinical Modi fication codes related to substance 'use ', dependence, or overdoses for alcohol, cannabis, nicotine, opioids, sedatives, stimulants, hallucinogens, or other substances. Cumulative growth rate and strati fied substance-related trends were calculated using generalized estimating equations. Predicted number of visits during the COVID-19 pandemic was generated using an auto -regressive time series analysis. Results: There were 106,793 substance-related visits involving 84,632 youth. From 2016 to 2021, substance-related visits increased by 47.9% and increased across all ages, demographics, regions, and payors. Visits of Hispanic youth experienced the greatest percentage growth (63.3%, p < .05) when compared to Non-Hispanic (NH) White (46.2%) or NH Black (49.8%) youth. All substances except sedatives experienced an increase in growth in visits. Cannabis accounted for the largest percentage of visits (52.2%) and experienced the greatest percentage growth during the study period (82.4%, p < .001). During the pandemic, publicly insured, female, NH Black, and Hispanic youth experienced a greater-than-predicted number of substance-related visits. Discussion: Substance-related visits to children 's hospitals are increasing for all demographics and nearly all substances. There were substantial increases in visits for most minoritized youth with a disproportionate rise among Hispanic youth. Visits over the pandemic were concentrated among publicly insured, female, NH Black, and Hispanic youth. Equitable large-scale investment is needed to address the rising morbidity of substance use among adolescents. (c) 2024 Society for Adolescent Health and Medicine. All rights reserved.

Purpose: Alcohol use disorder (AUD) is a pediatric-onset condition needing timely, effective treatment. Medications for AUD are part of nationally recommended treatments for youth. This study measured receipt of medications and behavioral health services for AUD and subsequent retention in care. Methods: This retrospective cohort study used claims data from > 4.7 million publicly insured youth aged 13-22 years in 15 states from 2014-2019. Timely treatment was defined as receipt of medication (naltrexone, acamprosate, or disulfiram) and/or behavioral health services within 30 days of incident AUD diagnosis. Associations of age and other characteristics with timely treatment were identified using modified Poisson regression. Retention in care (i.e., no period >= 60 days without claims) was studied using Cox regression. Results: Among 14,194 youth with AUD, 10,851 (76.4%) received timely treatment. Only 2.1% of youth received medication (alone or in combination); nearly all (97.9%) received behavioral health services only. Older (aged 16-17 years) and younger adolescents (aged 13-15 years) were 0.13 (95% confidence interval [CI], 0.07-0.26) and 0.24 (95% CI, 0.11-0.51) times as likely, respectively, to receive medications than young adults aged >= 21 years. Median retention in care for youth receiving medications was 119 days (interquartile range, 54-321) compared with 108 days (interquartile range, 43-243) for behavioral health services alone (p = .126). Young adults aged >= 18 years were 1.12 (95% CI, 1.06-1.18) times as likely to discontinue treatment compared with adolescents aged < 18 years. Discussion: This study found that more than seven in 10 youth received AUD treatment but only two in 100 received medications. Future studies should further characterize the effectiveness of medications and determine whether low rates of receipt represent underuse. (c) 2023 Society for Adolescent Health and Medicine. All rights reserved.

OBJECTIVE: Ear, nose, throat, and respiratory infections (ENTRI) may affect children with complex chronic conditions (CCC) differently than their peers. We compared ENTRI prev-alence and spending in children with and without CCCs. METHODS: Retrospective analysis of 3,880,456 children ages 0- to-18 years enrolled in 9 US state Medicaid programs in 2018 contained in the IBM Watson Marketscan Database. Type and number of CCCs were distinguished with Feudtner's system. ENTRI prevalence, defined as >= 1 healthcare encounters for ENTRI, and Medicaid spending on ENTRI were compared by CCC using chi-square tests and logistic regression. RESULTS: ENTRIs were greater in children with vs. without a CCC (57.7% vs 43.5% [P < .001]). Children with a CCC (5.5%, n = 213,425) accounted for nearly one-fourth ($145.8 million [US]) of total spending on ENTRI. Aside from throat and sinus infection, ENTRI prevalence increased with number of CCCs (P < .001). For example, as number of CCCs increased from zero to >= 3, lower-airway infection increased from 12.5% to 37.5%, P < .001 (OR 4.10; 95% CI 3.95-4.26). ENTRI spending attributable to inpatient care increased from 9.7% to 92.8% (P < .001) as the number of CCCs increased from zero to >= 3. CONCLUSION: Most children with a CCC pursued care for ENTRI in 2018 and these children accounted for a disproportion-ate share of ENTRI spending. Children with multiple CCCs had a high prevalence of lower-airway infection; most of their ENTRI spending was for inpatient care. Providers can use these findings to counsel patients and families and to inform future investiga-tions on how best to manage ENTRI in children with CCCs.

OBJECTIVE:To characterize resource utilization in the evaluation and treatment of hospitalized simple febrile seizure (SFS) patients in US tertiary pediatric hospitals.METHODS:This is a retrospective cohort study using the Pediatric Health Information System from 2010 to 2015. Children 6 months to 5 years of age who were inpatients with a diagnosis of SFS. Children who had brain magnetic resonance imaging (MRI), electroencephalography (EEG), or received anticonvulsants were compared with those who did not have testing or anticonvulsant treatment. Hospital-level variation in the utilization rates of MRI, EEG, or treatment with anticonvulsants was also evaluated.RESULTS:In Pediatric Health Information System-participating institutions, 8.4% (n=3640) of children presenting to the emergency department with SFS were hospitalized. Among these SFS inpatients, 57.8% (n= 2104) did not receive further evaluation with MRI/EEG or treatment with anticonvulsants. There was evidence of wide inter-hospital variation in resource utilization rates. The median (interquartile range) utilization rate was 6.2% (3.0 to 11.0%) for MRI, 28.5% (16.0 to 46.3%) for EEG and 17.1% (10.9 to 22.3%) for treatment with anticonvulsants.CONCLUSION:No specific hospital-level factors were identified that contributed to the variation in resource utilization in the evaluation and management of hospitalized SFS patients.

Importance:Although durable medical equipment and supplies (DMES) are commonly used to optimize the health and function in pediatric patients, little is known about the prevalence of use and spending on DMES. Objective:To categorize the Healthcare Common Procedure Coding System (HCPCS) for distinguishing DMES types, and to measure the prevalence and related spending of DMES in pediatric patients using Medicaid. Design, Setting, and Participants:This study is a cross-sectional analysis of the 2018 Merative Medicaid Database and included 4 569 473 pediatric patients aged 0 to 21 years enrolled in Medicaid in 12 US states from January 1 to December 31, 2018. Data were analyzed from February 2019 to April 2023. Exposure:DMES exposure was identified with the Centers for Medicare & Medicaid Services HCPCS codes. Three pediatricians categorized HCPCS DMES codes submitted by vendors for reimbursement of dispensed DMES into DMES types and end-organ systems; 15 expert reviewers refined the categorization (2576 DMES codes, 164 DMES types, 14 organ systems). Main Outcomes and Measures:The main outcome was DMES prevalence & Medicaid spending. The χ2 test was used to compare DMES prevalence and Wilcoxon rank sum tests were used to compare per-member-per-year (PMPY) spending by complex chronic conditions (CCC). Results:Of the 4 569 473 patients in the study cohort, 49.3% were female and 56.1% were aged 5 to 15 years. Patients used 133 of 164 (81.1%) DMES types. The DMES prevalence was 17.1% (95% CI, 17.0%-17.2%) ranging from 10.1% (95% CI, 10.0%-10.2%) in patients with no chronic condition to 60.9% (95% CI, 60.8%-61.0%) for patients with 2 or more CCCs. The PMPY DMES spending was $593, ranging from $349 for no chronic condition to $4253 for 2 or more CCCs. Lens (7.9%), vision frames (6.2%), and orthotics for orthopedic injury (0.8%) were the most common DME in patients with no chronic condition. Enteral tube / feeding supplies (19.8%), diapers (19.2%), lower extremity orthotics (12.3%), wheelchair (9.6%), oxygen (9.0%), and urinary catheter equipment (4.2%) were among the most common DMES in children with 2 or more CCCs. Conclusions and Relevance:In this cross-sectional study, HCPCS distinguished a variety of DME types and use across pediatric populations. Further investigation should assess the utility of the HCPCS DMES categorization with efforts to optimize the quality and safety of DMES use.

OBJECTIVES:To examine how outpatient mental health (MH) follow-up after a pediatric MH emergency department (ED) discharge varies by patient characteristics and to evaluate the association between timely follow-up and return encounters.METHODS:We conducted a retrospective study of 28 551 children aged 6 to 17 years with MH ED discharges from January 2018 to June 2019, using the IBM Watson MarketScan Medicaid database. Odds of nonemergent outpatient follow-up, adjusted for sociodemographic and clinical characteristics, were estimated using logistic regression. Cox proportional hazard models were used to evaluate the association between timely follow-up and risk of return MH acute care encounters (ED visits and hospitalizations).RESULTS:Following MH ED discharge, 31.2% and 55.8% of children had an outpatient MH visit within 7 and 30 days, respectively. The return rate was 26.5% within 6 months. Compared with children with no past-year outpatient MH visits, those with ≥14 past-year MH visits had 9.53 odds of accessing follow-up care within 30 days (95% confidence interval [CI], 8.75-10.38). Timely follow-up within 30 days was associated with a 26% decreased risk of return within 5 days of the index ED discharge (hazard ratio, 0.74; 95% CI, 0.63-0.91), followed by an increased risk of return thereafter.CONCLUSIONS:Connection to outpatient care within 7 and 30 days of a MH ED discharge remains poor, and children without prior MH outpatient care are at highest risk for poor access to care. Interventions to link to outpatient MH care should prioritize follow-up within 5 days of an MH ED discharge.

OBJECTIVES A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations. METHODS We conducted a cross-sectional analysis of the 2019 Kids’ Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator “in-hospital birth” and any categorized by the Pediatric Clinical Classification System as “liveborn” were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression). RESULTS In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million). CONCLUSIONS Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.

While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow‐up, and evaluate the association of ambulatory follow‐up with subsequent hospital‐based health care utilization.

Background Adolescents and young adults (AYAs) in Haiti experience a high unintended pregnancy rate, in part due to unmet contraception needs. Little is known about AYA opinions of and experiences with contraception that may explain remaining gaps in coverage. We aimed to describe barriers and facilitators to contraception use among AYAs in Haiti. Methods We conducted a cross-sectional survey and semi-structured qualitative interviews with a convenience sample of AYA females aged 14–24 in two rural communities in Haiti. The survey and semi-structured interviews assessed demographics, sexual health and pregnancy prevention behaviors and explored contraception opinions and experiences according to Theory of Planned Behavior constructs: attitudes, subjective norms, and perceived behavioral control. We used descriptive statistics to report means and responses to Likert scale and multiple-choice questions. Guided by content analysis, we analyzed interview transcripts through inductive coding and team debriefing. Results Among 200 survey respondents, 94% reported any past vaginal sexual activity, and 43% reported ever being pregnant. A large majority were trying to avoid pregnancy (75%). At last sexual activity, 127 (64%) reported use of any contraceptive method; Among them, condoms were the most common method (80%). Among those with previous condom use, most reported use less than half the time (55%). AYAs were concerned about parental approval of birth control use (42%) and that their friends might think they are looking for sex (29%). About one-third felt uncomfortable going to a clinic to ask for birth control. In interviews, AYAs desired pregnancy prevention but frequently noted concerns about privacy and parental, community and healthcare provider judgement for seeking care for reproductive health needs. AYAs also noted a lack of contraception knowledge, evident by frequent misconceptions and associated fears. Conclusion Among AYAs in rural Haiti, a large majority were sexually active and desire pregnancy avoidance, but few were using effective contraception due to numerous concerns, including privacy and fear of judgement. Future efforts should address these identified concerns to prevent unintended pregnancy and improve maternal and reproductive health outcomes in this population.

Although more guideline‐adherent care has been described in pediatric compared to adult trauma centers, we aimed to provide a more detailed characterization of management and resource utilization of children with intra‐abdominal injury (IAI) within pediatric centers. Our primary objective was to describe the epidemiology, diagnostic evaluation, and management of children with IAI across U.S. children's hospitals. Our secondary objective was to describe the interhospital variation in surgical management of children with IAI.

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Health care cost in the United States (US) is increasing exponentially, and healthcare providers are searching ways to provide high-quality care in a cost-efficient manner. Comparative effectiveness research aims to determine health care delivery strategies to inform practice and reduce unnecessary practice variation. Prior studies have identified priority topics for comparative effectiveness research in hospital pediatrics and general surgery, but they have not focused on ambulatory or same-day surgery [ [1] Keren R. Luan X. Localio R. Hall M. McLeod L. Dai D. Srivastava R. Prioritization of comparative effectiveness research topics in hospital pediatrics. Arch Pediatr Adolesc Med. 2012; 166 (Dec 1): 1155-1164https://doi.org/10.1001/archpediatrics.2012.1266 Google Scholar , [2] Cameron D.B. Graham D.A. Milliren C.E. Glass C.C. Feng C. Sidhwa F. Thangarajah H. Hall M. Rangel S.J. Quantifying the burden of inter hospital cost variation in pediatric surgery: implications for the prioritization of comparative effectiveness research. JAMA Pediatr. 2017; 171 (Feb 1)e163926https://doi.org/10.1001/jamapediatrics.2016.3926 Google Scholar ]. More than half of all surgeries in the US are performed as an outpatient procedure, thus, understanding high priority conditions, based on prevalence, cost and cost variation in ambulatory surgeries is important [ [3] Cullen K.A. Hall M.J. Golosinskiy A. Ambulatory surgery in the United States. Natl Health Stat Report. 2006; 11: 1-25 Google Scholar ].

Objective This study aimed to describe trends in the utilization of nucleic acid amplification (NAAT) testing for gonorrhea and chlamydia in US pediatric emergency departments. Nucleic acid amplification has been recommended over genital culture by the American Academy of Pediatrics and Centers for Disease Control and Prevention for children evaluated for sexual abuse. Methods We conducted a multicenter study of children aged 12 months to 11 years tested for gonorrhea and chlamydia between 2004 and 2018 at 22 hospitals in the Pediatric Health Information System. We included patients diagnosed with maltreatment concerns and/or genitourinary (GU) symptoms. The primary outcome was prevalence of testing with NAAT, culture, or both. We analyzed groups based on patient sex, as well as diagnoses of maltreatment versus GU symptoms. Results A total of 36,312 visits were analyzed. Visits were 73.4% girls and 26.6% boys. During the study period, there was an increase in use of NAAT-only testing for girls (49.3% to 94.3%; P < 0.001) and boys (54.5% to 96.1%; P < 0.001). There was a decrease in use of culture alone for girls (40% to 1.6%; P < 0.001) and boys (38.7% to 0.8%; P < 0.001). Use of both tests in the same encounter was higher among children diagnosed with maltreatment than GU symptoms, regardless of sex (P < 0.001). Conclusions Over a 14-year period, downtrend of culture use with increase in NAAT was observed, suggesting general adherence to evidence-based guidelines. Almost 10% of children diagnosed with maltreatment continued to be tested with culture. This could indicate provider concerns regarding test accuracy, legal admissibility, or lack of test availability.

Objectives Acute otitis media (AOM) is the most common reason for pediatric antibiotic prescriptions. The 2013 American Academy of Pediatrics' AOM guidelines recommend observation for nonsevere AOM. Our aim was to increase the percentage safety-net antibiotic prescription (SNAP) offered to patients 6 months of age or older diagnosed with AOM in 2 pediatric emergency departments (EDs) from a baseline of 0.5% to 15% in 20 months. Methods This is a quality improvement study at a quaternary pediatric medical center with 2 locations, both with EDs. A random chart review revealed that 27.5% of patients diagnosed with AOM in the ED would qualify for a SNAP, but only 0.5% were offered it. Quality improvement interventions were designed to improve safety-net antibiotic prescribing. Both EDs conducted multiple interventions, including algorithm development, provider education, and electronic medical record aids. The primary outcome measure was the percentage of patients offered a SNAP for AOM. Results A total of 8226 children 6 months of age or older were diagnosed with AOM in our 2 EDs during the 20-month intervention period. The percentage offered a SNAP increased at both EDs. One ED had a single shift in the mean to 7.9%, whereas the other had 2 shifts in the mean, an initial shift to 5.1% and a second to 7.3%. Providers consistently used the algorithm and electronic medical record aids. Conclusions Safety-net antibiotic prescriptions in conjunction with parent education was effective in reducing the use of immediate antibiotic prescriptions in children with AOM in 2 pediatric EDs. Offering a SNAP can reduce unnecessary use of antibiotics, which in turn may decrease antibiotic-related adverse events and antibiotic resistance.