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1.  Chronic conditions among children admitted to U.S. PICUs: their prevalence and impact on risk for mortality and prolonged length of stay 
Critical Care Medicine  2012;40(7):2196-2203.
OBJECTIVE
To estimate the prevalence of chronic conditions among children admitted to U.S. pediatric intensive care units (PICU) and to assess whether patients with complex chronic conditions (CCC) experience PICU mortality and prolonged LOS risk beyond that predicted by commonly-used severity-of-illness risk-adjustment models.
DESIGN, SETTING, & PATIENTS
Retrospective cohort analysis of 52,791 pediatric admissions to 54 U.S. PICUs that participated in the Virtual Pediatric Intensive Care Unit Performance System (VPS) database in 2008.
MEASUREMENTS
Hierarchical logistic regression models, clustered by PICU site, for PICU mortality and length of stay (LOS) > 15 days. Standardized mortality ratios (SMR) adjusted for severity-of-illness score alone and with CCC.
MAIN RESULTS
Fifty-three percent of PICU admissions had a CCC, 18.5% had a non-complex chronic conditions (NCCC). The prevalence of these conditions and their organ system subcategories varied considerably across sites. The majority of CCC subcategories were associated with significantly greater odds of PICU mortality (odds ratios [OR] 1.25–2.9, all P values <0.02) compared to having a non-complex chronic condition (NCCC) or no chronic condition, after controlling for age, gender, trauma, and severity-of-illness. Only respiratory, gastrointestinal, and rheumatologic/orthopedic/psychiatric CCC were not associated with increased odds of PICU mortality. All subcategories were significantly associated with prolonged LOS. All NCCC subcategories were either not associated or negatively associated with PICU mortality, and most were not associated with prolonged LOS, compared to having no chronic conditions. Among this group of PICUs, adding CCCs to risk-adjustment models led to greater model accuracy but did not substantially change unit-level SMRs.
CONCLUSIONS
Children with CCC were at greater risk for PICU mortality and prolonged LOS than those with no chronic conditions, but the magnitude of risk varied across subcategories. Inclusion of CCCs into models of PICU mortality improved model accuracy but had little impact on SMRs.
doi:10.1097/CCM.0b013e31824e68cf
PMCID: PMC3378726  PMID: 22564961
Child; Intensive Care Units, Pediatric; Mortality; Length of Stay; Chronic Disease; Risk Adjustment
2.  End-of-Life Discussions and Advance Care Planning for Children on Long-Term Assisted Ventilation with Life-Limiting Conditions 
Journal of palliative care  2012;28(1):21-27.
Families of children with life-limiting conditions who are on long-term assisted ventilation need to undertake end-of-life advance care planning (ACP) in order to align their goals and values with the inevitability of their child's condition and the risks it entails. To discuss how best to conduct ACP in this population, we performed a retrospective analysis of end-of-life discussions involving our deceased ventilator-assisted patients between 1987 and 2009. A total of 34 (72 percent) of 47 study patients were the subject of these discussions; many discussions occurred after acute deterioration. They resulted in directives to forgo or limit interventions for 21 children (45 percent). We surmise that many families were hesitant to discuss end-of-life issues during periods of relative stability. By offering anticipatory guidance and encouraging contemplation of patients’ goals both in times of stability and during worsening illness, health care providers can better engage patients’ families in ACP. As the child's condition progresses, the emphasis can be recalibrated. How families respond to such encouragement can also serve as a gauge of their willingness to pursue ACP.
PMCID: PMC3682656  PMID: 22582468
3.  Predictors of Clinical Outcomes and Hospital Resource Use of Children After Tracheotomy 
Pediatrics  2009;124(2):563-572.
OBJECTIVES
The objectives are to describe health outcomes and hospital resource use of children after tracheotomy and identify patient characteristics that correlate with outcomes and hospital resource use.
PATIENTS AND METHODS
A retrospective analysis of 917 children aged 0 to 18 years undergoing tracheotomy from 36 children’s hospitals in 2002 with follow-up through 2007. Children were identified from ICD-9-CM tracheotomy procedure codes. Comorbid conditions (neurologic impairment [NI], chronic lung disease, upper airway anomaly, prematurity, and trauma) were identified with ICD-9-CM diagnostic codes. Patient characteristics were compared with in-hospital mortality, decannulation, and hospital resource use by using generalized estimating equations.
RESULTS
Forty-eight percent of children were ≤6 months old at tracheotomy placement. Chronic lung disease (56%), NI (48%), and upper airway anomaly (47%) were the most common underlying comorbid conditions. During hospitalization for tracheotomy placement, children with an upper airway anomaly experienced less mortality (3.3% vs 11.7%; P < .001) than children without an upper airway anomaly. Five years after tracheotomy, children with NI experienced greater mortality (8.8% vs 3.5%; P≤.01), less decannulation (5.0% vs 11.0%; P≤.01), and more total number of days in the hospital (mean [SE]: 39.5 [4.0] vs 25.6 [2.6] days; P≤.01) than children without NI. These findings remained significant (P < .01) in multivariate analysis after controlling for other significant cofactors.
CONCLUSIONS
Children with upper airway anomaly experienced less mortality, and children with NI experienced higher mortality rates and greater hospital resource use after tracheotomy. Additional research is needed to explore additional factors that may influence health outcomes in children with tracheotomy.
doi:10.1542/peds.2008-3491
PMCID: PMC3614342  PMID: 19596736
tracheotomy; children; mortality; hospitalization; health services; outcomes
4.  Patient characteristics associated with in-hospital mortality in children following tracheotomy 
Archives of disease in childhood  2010;95(9):703-710.
Objectives
To identify children at risk for in-hospital mortality following tracheotomy.
Design
Retrospective cohort study.
Setting
25 746 876 US hospitalisations for children within the Kids’ Inpatient Database 1997, 2000, 2003 and 2006.
Participants
18 806 hospitalisations of children ages 0–18 years undergoing tracheotomy, identified from ICD-9-CM tracheotomy procedure codes.
Main outcome measure
Mortality during the initial hospitalisation when tracheotomy was performed in relation to patient demographic and clinical characteristics (neuromuscular impairment (NI), chronic lung disease, upper airway anomaly, prematurity, congenital heart disease, upper airway infection and trauma) identified with ICD-9-CM codes.
Results
Between 1997 and 2006, mortality following tracheotomy ranged from 7.7% to 8.5%. In each year, higher mortality was observed in children undergoing tracheotomy who were aged <1 year compared with children aged 1–4 years (mortality range: 10.2–13.1% vs 1.1–4.2%); in children with congenital heart disease, compared with children without congenital heart disease (13.1–18.7% vs 6.2–7.1%) and in children with prematurity, compared with children who were not premature (13.0–19.4% vs 6.8–7.3%). Lower mortality was observed in children with an upper airway anomaly compared with children without an upper airway anomaly (1.5–5.1% vs 9.1–10.3%). In 2006, the highest mortality (40.0%) was observed in premature children with NI and congenital heart disease, who did not have an upper airway anomaly.
Conclusions
Congenital heart disease, prematurity, the absence of an upper airway anomaly and age <1 year were characteristics associated with higher mortality in children following tracheotomy. These findings may assist provider communication with children and families regarding early prognosis following tracheotomy.
doi:10.1136/adc.2009.180836
PMCID: PMC3118570  PMID: 20522454

Results 1-4 (4)