BACKGROUND AND OBJECTIVES Individualized, weight-based opioid dosing poses safety risks and contributes to inefficient medication delivery processes. Dose banding is a patient safety strategy to reduce dosing errors through standardized doses based on weight ranges. Study objectives were (1) determine the frequency of dosing deviation from reference ranges of common intravenous (IV) and oral opioid medications, (2) evaluate the differences in dosing deviations by age, and (3) determine the potential reduction in dose variation that could be achieved by dose banding. METHODS We conducted a cross-sectional analysis of hospitalized children ≥2 months to ≤24 months old who received IV morphine, oral methadone, or oral oxycodone at a single center. Dosing was categorized as no dosing deviation (within ±5% of the reference range), negative dosing deviation (>5% below the reference range), or positive dosing deviation (>5% above the reference range). Descriptive and bivariate analyses were conducted. RESULTS A total of 3361 opioid doses met the inclusion criteria. A total of 2663 (79.2%) had no dosing deviation, 214 (6.3%) demonstrated negative deviations, and 484 (14.4%) demonstrated positive deviations. Dosing deviations were more frequent among subjects ≥2 months to ≤6 months old for oral methadone and oxycodone (P < .0001) and more frequent among older age group for IV morphine (P < .0001). Dose banding has the potential to reduce the number of unique doses prescribed for all medications by 75% while eliminating unintended dosing deviations. CONCLUSIONS A total of 20% of opioid doses prescribed to children ≤24 months of age are outside the recommended ranges. Dose banding represents a promising method for simplifying opioid prescribing in the pediatric inpatient setting.

incorporation into clinical practice amongst residents.By promoting awareness, we can help reduce stigma, increase knowledge about mental health, and encourage open conversations about suicide.

Conclusions: These parental surveys and weight records noted a possible trend in improved weight control with increasing amounts of virtual schooling.The possible causes could range broadly with environment changes during the COVID-19 pandemic.Future research could reveal a trend of healthier diet options when staying home or of more exercise to fill the increase in free time.These correlations of virtual schooling may lead to further adoption in schools as world events continue to challenge our daily life.

OBJECTIVE:Firearms are a major cause of pediatric injury. An analysis of opioid use following pediatric firearm injury has not previously been reported. Our objective was to determine the prevalence and factors associated with persistent opioid use among pediatric nonfatal firearm injury victims. METHODS:We performed a retrospective cohort study using 2015-18 claims data from the Merative MarketScan Multi-State Medicaid and Commercial Databases, utilizing International Classification of Diseases, Tenth Revision codes for firearm injury and National Drug Codes for opioids. Dispensed opioid claims were used as a proxy for opioid use. Opioid exposure was defined both dichotomously and continuously (by the total number of opioid days prescribed) in the 30 days following discharge from firearm injury index encounter. Persistent opioid use was defined as ≥1 opioid claim(s) in the 90 to 270 days following index encounter. Multivariable logistic regression analysis was performed to determine whether covariates of interest were associated with greater odds of persistent opioid use. RESULTS:Our cohort consisted of 2110 children who experienced nonfatal firearm injury (mean age 13.5, 80.9% male, 79.5% Medicaid) with 608 children (28.8%) exposed to opioids. Of patients exposed to opioids, 10.4% developed persistent opioid use. In adjusted analyses, each opioid day dispensed during the exposure period represented 5% greater odds of experiencing persistent opioid use. CONCLUSIONS:Clinicians caring for children injured by firearms should be aware of the risk of developing persistent opioid use and balance that risk with the need to sufficiently control pain.

speaking patients who received language-concordant return precautions.Moving forward, we will complete additional PDSA cycles to identify barriers and areas for improvement with our dot phrase intervention.We will also begin to target to our secondary aim to increase the percentage of discharge instructions for common pediatric presentations in Spanish to families who have identified Spanish as their primary language.

BACKGROUND AND OBJECTIVESWritten discharge instructions help to bridge hospital-to-home transitions for patients and families, though substantial variation in discharge instruction quality exists. We aimed to assess the association between participation in an Institute for Healthcare Improvement Virtual Breakthrough Series collaborative and the quality of pediatric written discharge instructions across 8 US hospitals. METHODSWe conducted a multicenter, interrupted time-series analysis of a medical records-based quality measure focused on written discharge instruction content (0-100 scale, higher scores reflect better quality). Data were from random samples of pediatric patients (N = 5739) discharged from participating hospitals between September 2015 and August 2016, and between December 2017 and January 2020. These periods consisted of 3 phases: 1. a 14-month precollaborative phase; 2. a 12-month quality improvement collaborative phase when hospitals implemented multiple rapid cycle tests of change and shared improvement strategies; and 3. a 12-month postcollaborative phase. Interrupted time-series models assessed the association between study phase and measure performance over time, stratified by baseline hospital performance, adjusting for seasonality and hospital fixed effects. RESULTSAmong hospitals with high baseline performance, measure scores increased during the quality improvement collaborative phase beyond the expected precollaborative trend (+0.7 points/month; 95% confidence interval, 0.4-1.0; P < .001). Among hospitals with low baseline performance, measure scores increased but at a lower rate than the expected precollaborative trend (-0.5 points/month; 95% confidence interval, -0.8 to -0.2; P < .01). CONCLUSIONSParticipation in this 8-hospital Institute for Healthcare Improvement Virtual Breakthrough Series collaborative was associated with improvement in the quality of written discharge instructions beyond precollaborative trends only for hospitals with high baseline performance.

Introduction Telehealth can expand quality care to patients unable to access specialty health services. The purpose of this study was to compare changes in body mass index (BMI) and laboratory values in patients visiting a weight management clinic for in-person versus telehealth counselling. Methods A retrospective cohort study of active program participants from two to 22 years old was conducted. Change in BMI, BMI z-score, low-density lipoprotein (LDL), alanine aminotransferase (ALT), and glycated haemoglobin (HbA(1c)) levels were measured at each patient's initial and final visit for the study period, and the difference was analysed for significance. Change in BMI z-score was analysed for non-inferiority of the telehealth group using a delta of 0.15. Results We evaluated 1019 of 1126 (90.5%) in-person patients and 58 of 75 (77.3%) of telehealth clinic patients. The mean initial BMI was 32.2 and 32.6 for the in-person and telehealth groups, respectively. There were mean decreases in BMI z-scores of 0.044 and 0.032 in the in-person and telehealth groups, respectively, P < 0.001 with a margin of 0.15. The changes in mean HbA(1c) (p = 0.59), mean LDL (p = 0.93), and a mean ALT (p = 0.09) were not significant, although only a minority of patients followed-up for lab draws, limiting interpretation of these results. Discussion Attending a weight management clinic via telehealth was non-inferior to in-person visits for enacting a clinically significant change in BMI z-score, mitigating the effect of sample size on BMI z-score results. These findings give credibility to telehealth as a means of increasing access to paediatric weight management care.

We sought to identify the most common diagnostic categories linked to dispensed opioid prescriptions among children 1–36 months old and changes in patterns over the years 2000 to 2017. This study used South Carolina’s Medicaid claims data of pediatric dispensed outpatient opioid prescriptions between 2000 and 2017. The major opioid-related diagnostic category (indication) for each prescription was identified using visit primary diagnoses and the Clinical Classification System (AHRQ-CCS) software. The variables of interest were the rate of opioid prescriptions per 1,000 visits for each diagnostic category and the relative percentage of opioid prescriptions assigned to each category compared to all categories. Six major diagnostic categories were identified; Diseases of the respiratory system (RESP), Congenital anomalies (CONG), Injury (INJURY), Diseases of the nervous system and sense organs (NEURO), Diseases of the digestive system (GI), and Diseases of the genitourinary system (GU). The overall rate of dispensed opioid prescriptions per category declined significantly for four diagnostic categories throughout the study period, RESP by 15.13, INJURY by 8.49, NEURO by 7.33, and GI by 5.93. Two categories increased during the same time, CONG (by 9.47) and GU (by 6.98). RESP was the most prevalent category linked to a dispensed opioid prescription within 2010–2012 (almost 25%) but CONG was the most prevalent by 2014 (17.77%). Among Medicaid children 1–36 months old, annual dispensed opioid prescription rates declined for most major diagnostic categories (RESP, INJURY, NEURO, and GI). Future studies should explore alternatives to current opioid dispensing practices for GU and CONG cases. Eventhough opioid is a high-risk medication for children, it is continued to be prescribed to pediatric population. A little is known about the diagnoses associated with opioid prescribing among children 1–36 months old and their trends. This study demonstrates that opioid prescriptions linked to respiratory diagnosis have become less prevalent, surpassed by opioids prescribed for surgical conditions.

OBJECTIVE:The objective of this study was to evaluate opioid use trajectories among a sample of 10,138 Medicaid patients receiving one of six index surgeries: lumbar spine, total knee arthroplasty, cholecystectomy, appendectomy, colon resection, and tonsillectomy.DESIGN:Retrospective cohort.SETTING:Administrative claims data.PATIENTS AND PARTICIPANTS:Patients, aged 13 years and older, with 15-month continuous Medicaid eligibility surrounding index surgery, were selected from single-state Medicaid medical and pharmacy claims data for surgeries performed between 2014 and 2017.INTERVENTIONS:None.MAIN OUTCOME MEASURES:Baseline comorbidities and presurgery opioid use were assessed in the 6 months prior to admission, and patients' opioid use was followed for 9 months post-discharge. Generalized linear model with log link and Poisson distribution was used to determine risk of chronic opioid use for all risk factors. Group-based trajectory models identified groups of patients with similar opioid use trajectories over the 15-month study period.RESULTS:More than one in three (37.7 percent) patients were post-surgery chronic opioid users, defined as the dichotomous outcome of filling an opioid prescription 90 or more days after surgery. Key variables associated with chronic post-surgery opioid use include presurgery opioid use, 30-day post-surgery opioid use, and comorbidities. Latent trajectory modeling grouped patients into six distinct opioid use trajectories. Associates of trajectory group membership are reported.CONCLUSIONS:Findings support the importance of surgeons setting realistic patient expectations for post-surgical opioid use, as well as the importance of coordination of post-surgical care among patients failing to fully taper off opioids within 1-3 months of surgery.

Racial differences in opioid dispensing for diseases of the respiratory system (RESP) and injury (INJURY) outpatient visits among patients ≤ 3 years old were examined. Outpatient claims data of South Carolina Medicaid children were analyzed over three three-year periods. The variable of interest was the triennial rate of dispensed opioid prescriptions per 1000 visits for RESP and INJURY diagnoses across racial/ethnic groups. Overall, dispensed opioid prescription rates related to RESP declined for all racial/ethnic categories. White children had the highest dispensing rate for RESP indications in the first period (5.6), followed by Black (4.5), and Hispanic (4.1). The likelihood of White children being prescribed opioids was higher than Blacks, and this was persistent over the studied time (rate ratios from 1.24 to 1.22, respectively). Overall opioid dispensing rates related to injury declined during the studied time. Hispanics had the highest dispensing rate for INJURY (20.1 to 14.8 to 16.1, respectively) followed by White (16.1 to 13.1 to 10.4, respectively). Relative differences in the dispensing rates across groups increased over time (Hispanics vs. White: rate ratios from 1.25 to 1.55, Hispanics vs. Black: from 1.52 to 2.24, and White vs. Black: from 1.24 to 1.44, respectively). There are considerable differences in the dispensing rates across racial/ethnic groups, especially in injury-related prescribing.

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0–18 years old between 2000–2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran–Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926–0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000–2020, adolescents 12–18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Study Design. Retrospective administrative database review. Objective. Analyze patterns of opioid use in patients undergoing lumbar surgery and determine associated risk factors in a Medicaid population. Summary of Background Data. Opioid use in patients undergoing surgery for degenerative lumbar spine conditions is prevalent and impacts outcomes. There is limited information defining the scope of this problem in Medicaid patients. Materials and Methods. Longitudinal cohort study of adult South Carolina (SC) Medicaid patients undergoing lumbar surgery from 2014 to 2017. All patients had continuous SC Medicaid coverage for 15 consecutive months, including six months before and nine months following surgery. The primary outcome was a longitudinal assessment of postoperative opioid use to determine trajectories and group-based membership using latent modeling. Univariate and multivariable modeling was conducted to assess risk factors for group-based trajectory modeling and chronic opioid use (COU). Results. A total of 1455 surgeries met inclusion criteria. Group-based trajectory model demonstrated patients fit into five groups; very low use (23.4%), rapid wean following surgery (18.8%), increasing use following surgery (12.9%), slow wean following surgery (12.6%) and sustained high use (32.2%). Variables predicting membership in high opioid use included preoperative opioid use, younger age, longer length of stay, concomitant medications, and readmissions. More than three quarter of patients were deemed COUs (76.4%). On bivariate analysis, patients with degenerative disk disease were more likely to be COUs (24.8% vs. 18.6%; P =0.0168), more likely to take opioids before surgery (88.5% vs. 61.9%; P <0.001) and received higher amounts of opioids during the 30 days following surgery (mean morphine milligram equivalents 59.6 vs. 25.1; P <0.001). Conclusions. Most SC Medicaid patients undergoing lumbar elective lumbar spine surgery were using opioids preoperatively and continued long-term use postoperatively at a higher rate than previously reported databases. Preoperative and perioperative intake, degenerative disk disease, multiple prescribers, depression, and concomitant medications were significant risk factors.

Abstract Background Opioids are commonly used to manage orthopedic pain in those undergoing total knee arthroplasty (TKA). There are limited studies assessing patterns of perioperative opioid use and risk factors for chronic use in patients undergoing TKA. Methods This is a retrospective longitudinal cohort study of Medicaid enrollees undergoing TKA between 2014 and 2017 using de-identified medical and pharmacy claims. The primary outcome was chronic opioid use (opioid prescription filled 90–270 days following TKA). Trajectory group membership was determined by identifying distinct groups of patients with similar patterns of daily morphine milligram equivalent (MME) values during the postsurgery follow-up period. Results In total, 1666 TKA surgeries performed in 1507 patients were included; 69% of patients were classified as chronic opioid users. Multivariable analyses identified prior opioid use, high opioid doses during the month after TKA, concomitant mood therapies and benzodiazepines, and comorbid conditions as important risk factors. Group-based trajectory analysis identified five distinct post-TKA surgery opioid use phenotypes with several key characteristics predicting group membership. Conclusions This large-scale analysis demonstrated that chronic opioid use was common after TKA surgery and established several important risk factors for chronic use following TKA. Novel analysis revealed five distinct opioid use trajectories and identified key characteristics to help guide clinicians when determining perioperative opioid use. Results demonstrate that interventional studies attempting to reduce opioids after TKA are needed if reductions in long-term use are to be realized in this high-risk patient population.

Background: The past 5 years have witnessed a concerted national effort to assuage the rising tide of the opioid misuse in our country. Surgical procedures often serve as the initial exposure of children to opioids, however the trajectory of use following these exposures remains unclear. We hypothesized that opioid exposure following appendectomy would increase the risk of persistent opioid use among publicly insured children.Study design: A retrospective longitudinal cohort study was conducted on South Carolina Medicaid en-rollees who underwent appendectomy between January 2014 and December 2017 using administrative claims data. The primary outcome was chronic opioid use. Generalized linear models and finite mixture models were employed in analysis.Results: 1789 Medicaid pediatric patients underwent appendectomy and met inclusion criteria. The mean age was 11.1 years and 40.6% were female. Most patients (94.6%) did not receive opioids prior to surgery. Opioid prescribing >= 90 days after surgery (chronic opioid use) occurred in 127 (7.1%) patients, of which 102 (80.3%) had no opioid use in the preexposure period. Risk factors for chronic opioid use included non-naive opioid status, re-hospitalization more than 30 days following surgery, multiple opioid pre-scribers, age, and multiple antidepressants/antipsychotic prescriptions.Group-based trajectory analysis demonstrated four distinct post-surgical opioid use patterns: no opi-oid use (91.3%), later use (6.7%), slow wean (1.9%), and higher use throughout (0.4%). Conclusion: Opioid exposure after appendectomy may serve as a priming event for persistent opioid use in some children. Eighty percent of children who developed post-surgical persistent opioid use had not received opioids in the 90 days leading up to surgery. Several mutable and immutable factors were identified to target future effort s toward opioid minimization in this at-risk patient population. Level of evidence: III.(c) 2022 Elsevier Inc. All rights reserved.

BACKGROUND The number of youth presenting to hospitals with suicidality and/or self-harm has increased substantially in recent years. We implemented a multihospital quality improvement (QI) collaborative from February 1, 2018 to January 31, 2019, aiming for an absolute increase in hospitals' mean rate of caregiver lethal means counseling (LMC) of 10 percentage points (from a baseline mean performance of 68% to 78%) by the end of the collaborative, and to evaluate the effectiveness of the collaborative on LMC, adjusting for secular trends. METHODS This 8 hospital collaborative used a structured process of alternating learning sessions and action periods to improve LMC across hospitals. Electronic medical record documentation of caregiver LMC was evaluated during 3 phases: precollaborative, active QI collaborative, and postcollaborative. We used statistical process control to evaluate changes in LMC monthly. Following collaborative completion, interrupted time series analyses were used to evaluate changes in the level and trend and slope of LMC, adjusting for covariates. RESULTS In the study, 4208 children and adolescents were included-1314 (31.2%) precollaborative, 1335 (31.7%) during the active QI collaborative, and 1559 (37.0%) postcollaborative. Statistical process control analyses demonstrated that LMC increased from a hospital-level mean of 68% precollaborative to 75% (February 2018) and then 86% (October 2018) during the collaborative. In interrupted time series analyses, there were no significant differences in LMC during and following the collaborative beyond those expected based on pre-collaborative trends. CONCLUSIONS LMC increased during the collaborative, but the increase did not exceed expected trends. Interventions developed by participating hospitals may be beneficial to others aiming to improve LMC for caregivers of hospitalized youth with suicidality.

Background: Commercial insurance data show that chronic opioid use in opioid-naive patients occurs in 1.5% to 8% of patients undergoing surgical procedures, but little is known about patients with Medicaid. Methods: Opioid prescription data and medical coding data from 4,788 Medicaid patients who underwent cholecystectomy were analyzed to determine opioid use patterns. Results: A total of 54.4% of patients received opioids prior to surgery, and 38.8% continued to fill opioid prescriptions chronically; 27.1% of opioid-naive patients continued to get opioids chronically. Patients who received >= 50 MME/d had nearly 8 times the odds of chronic opioid use. Each additional opioid prescription filled within 30 days was associated with increased odds of chronic use (odds ratio: 1.71). Conclusion: Opioid prescriptions are common prior to cholecystectomy in Medicaid patients, and 38.8% of patients continue to receive opioid prescriptions well after surgical recovery. Even 27.1% of opioid-naive patients continued to receive opioid prescriptions chronically. Published by Elsevier Inc.

OBJECTIVE: To examine performance on quality measures for pediatric inpatient suicidal ideation/self-harm care, and whether performance is associated with reutilization. METHODS: Retrospective observational 8 hospital study of patients [N = 1090] aged 5 to 17 years hospitalized for suicidal ideation/self-harm between 9/1/14 and 8/31/16. Two medical records-based quality measures assessing suicidal ideation/self-harm care were evaluated, one on counseling caregivers regarding restricting access to lethal means and the other on communication between inpatient and outpatient providers regarding the follow-up plan. Multivariable logistic regression assessed associations between quality measure scores and 1) hospital site, 2) patient demographics, and 3) 30-day emergency department return visits and inpatient readmissions. RESULTS: Medical record documentation revealed that, depending on hospital site, 17% to 98% of caregivers received lethal means restriction counseling (mean 70%); inpatient-to-outpatient provider communication was documented in 0% to 51% of cases (mean 16%). The odds of documenting receipt of lethal means restriction counseling was higher for caregivers of female patients compared to caregivers of male patients (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI], 1.07-2.14). The odds of documenting inpatient-to-outpatient provider follow-up plan communication was lower for Black patients compared to White patients (aOR 0.45, 95% CI, 0.24-0.84). All-cause 30-day readmission was lower for patients with documented caregiver receipt of lethal means restriction counseling (aOR 0.48, 95% CI, 0.28-0.83). CONCLUSIONS: This study revealed disparities and deficits in the quality of care received by youth with suicidal ideation/self-harm. Providing caregivers lethal means restriction counseling prior to discharge may help to prevent readmission.

BACKGROUND AND OBJECTIVES: Despite published declines in opioid prescribing and dispensing to children in the past decade, in few studies have researchers evaluated all children in 1 state or examined changes in mean daily opioid dispensed. In this study, we evaluated changes in the rate of dispensed opioid analgesics and the mean daily opioid dispensed to persons 0 to 18 years old in 1 state over an 8-year period. METHODS: We identified opioid analgesics dispensed to children 0 to 18 years old between 2010 and 2017 using South Carolina prescription drug monitoring program data. We used generalized linear regression analyses to examine changes over time in the following: (1) rate of dispensed opioid prescriptions and (2) mean daily morphine milligram equivalents (MMEs) per prescription. RESULTS: From the first quarter of 2010 to the end of the fourth quarter of 2017, the quarterly rate of opioids dispensed decreased from 18.68 prescriptions per 1000 state residents to 12.03 per 1000 residents (P < .0001). The largest declines were among the oldest individuals, such as the 41.2% decline among 18-year-olds. From 2010 through 2017, the mean daily MME dispensed declined by 7.6%, from 40.7 MMEs per day in 2010 to 37.6 MMEs per day in 2017 (P < .0001), but the decrease was limited to children 0 to 9 years old. CONCLUSIONS: The rate of opioid analgesic prescriptions dispensed to children 0 to 18 years old in South Carolina declined by 35.6% over the years 2010–2017; however, the MME dispensed per day declined minimally, suggesting that more can be done to improve opioid prescribing and dispensing.

BACKGROUND:Pediatric hospital medicine (PHM) became a subspecialty of the American Board of Pediatrics (ABP) in 2016. Starting in 2019, residency graduates are required to complete fellowship training to qualify for PHM board eligibility. These requirements pose unique challenges to internal medicine-pediatrics (med-peds) residents interested in practicing combined adult hospital medicine (HM) and PHM. OBJECTIVE:To describe the needs of med-peds residents interested in PHM fellowship training and how the current PHM training environment can meet these needs. METHODS:We conducted two cross-sectional electronic survey studies: one of med-peds residents and one of PHM fellowship program directors (FDs). Surveys were distributed to resident and FD listservs. Questions were designed using an iterative consensus process among authors. Responses were analyzed with descriptive statistics. RESULTS:Four hundred sixty-six residents responded to the resident survey. Ninety-six percent (n = 446) had considered a career in HM. Almost all (n = 456, 97.9%) respondents indicated a preference for a fellowship with both adult HM and PHM clinical training. Subspecialty designation decreased desire to pursue a career including PHM for 90.1% of respondents. Twenty-eight (58.3%) FDs responded to the FD survey. Fifteen (53.6%) programs reported being able to accommodate adult HM and PHM clinical time. CONCLUSION:The majority of resident respondents reported a desire for a PHM fellowship with clinical time in both PHM and adult HM. Approximately 30% of current US PHM fellowship programs can accommodate adult HM practice for med-peds fellows, and many other programs would be willing to explore such opportunities.