Sanjay Mahant, MD, FRCPC, MSc

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

Children with medical complexity (CMC) have complex and chronic health conditions that often involve multiple organ systems and severely affect cognitive and physical functioning. Although the prevalence of CMC is low (1% of all children), they account for nearly one‐fifth of all pediatric admissions and one‐half of all hospital days and charges in the United States.[1] Over the last decade, CMC have had a particularly large and increasing impact in tertiary‐care children's hospitals.[1, 2] The Institute of Medicine has identified CMC as a priority population for a revised healthcare system.[3]

Medical homes, hospitals, health plans, states, federal agencies, and others are striving to reduce excessive hospital use in CMC because of its high cost.[4, 5, 6] Containing length of stay (LOS)an increasingly used indicator of the time sensitiveness and efficiency of hospital careis a common aim across these initiatives. CMC have longer hospitalizations than children without medical complexity. Speculated reasons for this are that CMC tend to have (1) higher severity of acute illnesses (eg, pneumonia, cellulitis), (2) prolonged recovery time in the hospital, and (3) higher risk of adverse events in the hospital. Moreover, hospital clinicians caring for CMC often find it difficult to determine discharge readiness, given that many CMC do not return to a completely healthy baseline.[7]

Little is known about long LOS in CMC, including which CMC have the highest risk of experiencing such stays and which stays might have the greatest opportunity to be shortened. Patient characteristics associated with prolonged length of stay have been studied extensively for many pediatric conditions (eg, asthma).[8, 9, 10, 11, 12, 13, 14] However, most of these studies excluded CMC. Therefore, the objectives of this study were to examine (1) the prevalence of long LOS in CMC, (2) patient characteristics associated with long LOS, and (3) hospital‐to‐hospital variation in prevalence of long LOS hospitalizations.

METHODS

RESULTS

Study Population

There were 954,018 hospitalizations of 217,163 CMC at 44 children's hospitals included for analysis. Forty‐seven percent of hospitalizations were for females, 49.4% for non‐Hispanic whites, and 61.1% for children with government insurance. Fifteen percent (n = 142,082) had a long LOS of 10 days. The median (IQR) LOS of hospitalizations <10 days versus 10 days were 2 (IQR, 14) and 16 days (IQR, 1226), respectively. Long LOS hospitalizations accounted for 61.1% (3.7 million) hospital days and 61.8% ($13.7 billion) of total hospitalization costs for all CMC in the cohort (Table 1).

Table 1.Demographic, Clinical, and Hospitalization Characteristics of Hospitalized Children With Medical Complexity by Length of Stay*

Characteristic	Overall (n = 954,018)	Length of Stay
		<10 Days (n = 811,936)	10 Days (n = 142,082)
NOTE: Abbreviations: IQR, interquartile range. *All comparisons were significant at the P < 0.001 level.
Age at admission, y, %
<1	14.6	12.7	25.7
14	27.1	27.9	22.4
59	20.1	21.0	14.9
1018	33.6	34.0	31.7
18+	4.6	4.4	5.4
Gender, %
Female	47.0	46.9	47.5
Race/ethnicity, %
Non‐Hispanic white	49.4	49.4	49.4
Non‐Hispanic black	23.1	23.8	19.3
Hispanic	18.2	17.8	20.4
Asian	2.0	1.9	2.3
Other	7.4	7.1	8.6
Complex chronic condition, %
Any	79.5	77.3	91.8
Technology assistance	37.1	34.1	54.2
Gastrointestinal	30.0	27.2	45.9
Neuromuscular	28.2	27.7	30.9
Cardiovascular	16.8	14.5	29.9
Respiratory	14.1	11.5	29.4
Congenital/genetic defect	17.2	16.7	20.2
Metabolic	9.9	8.9	15.4
Renal	10.1	9.5	13.8
Hematology/emmmunodeficiency	11.7	12.0	10.0
Neonatal	3.8	3.1	7.7
Transplantation	4.5	4.2	6.7
Clinical risk group, %
Chronic condition in 2 systems	68.4	71.2	53.9
Catastrophic chronic condition	31.4	28.8	46.1
Distance from hospital to home residence in miles, median [IQR]	16.2 [7.440.4]	15.8 [7.338.7]	19.1 [8.552.6]
Transferred from outside hospital (%)	6.5	5.3	13.6
Admitted for surgery, %	23.4	20.7	38.7
Use of intensive care, %	19.6	14.9	46.5
Discharge disposition, %
Home	91.2	92.9	81.4
Home healthcare	4.5	3.5	9.9
Other	2.9	2.6	4.5
Postacute care facility	1.1	0.8	3.1
Died	0.4	0.3	1.1
Payor, %
Government	61.1	60.6	63.5
Private	33.2	33.6	30.9
Other	5.7	5.7	5.7
Hospital resource use
Median length of stay [IQR]	3 [16]	2 [14]	16 [1226]
Median hospital cost [IQR]	$8,144 [$4,122$18,447]	$6,689 [$3,685$12,395]	$49,207 [$29,444$95,738]
Total hospital cost, $, billions	$22.2	$8.5	$13.7

Demographics and Clinical Characteristics of Children With and Without Long LOS

Compared with hospitalized CMC with LOS <10 days, a higher percentage of hospitalizations with LOS 10 days were CMC age <1 year (25.7% vs 12.7%, P < 0.001) and Hispanic (20.4% vs 17.8%, P < 0.001). CMC hospitalizations with a long LOS had a higher percentage of any CCC (91.8% vs 77.3%, P < 0.001); the most common CCCs were gastrointestinal (45.9%), neuromuscular (30.9%), and cardiovascular (29.9%). Hospitalizations of CMC with a long LOS had a higher percentage of a catastrophic chronic condition (46.1% vs 28.8%, P < 0.001) and technology dependence (46.1% vs 28.8%, P < 0.001) (Table 1).

Hospitalization Characteristics of Children With and Without Long LOS

Compared with hospitalizations of CMC with LOS <10 days, hospitalizations of CMC with a long LOS more often involved transfer in from another hospital at admission (13.6% vs 5.3%, P < 0.001). CMC hospital stays with a long LOS more often involved surgery (38.7% vs 20.7%, P < 0.001) and use of intensive care (46.5% vs 14.9%; P < 0.001). A higher percentage of CMC with long LOS were discharged with home health services (9.9% vs 3.5%; P < 0.001) (Table 1).

The most common admitting diagnoses and CCCs for hospitalizations of CMC with long LOS are presented in Table 2. The two most prevalent APR‐DRGs in CMC hospitalizations lasting 10 days or longer were cystic fibrosis (10.7%) and respiratory system disease with ventilator support (5.5%). The two most common chronic condition characteristics represented among long CMC hospitalizations were gastrointestinal devices (eg, gastrostomy tube) (39.7%) and heart and great vessel malformations (eg, tetralogy of Fallot) (12.8%). The 5 most common CCC subcategories, as listed in Table 2, account for nearly 100% of the patients with long LOS hospitalizations.

Table 2.Most Common Reasons for Admission and Specific Complex Chronic Conditions for Hospitalized Children With Medical Complexity Who Had Length of Stay 10 Days

NOTE: *Reason for admission identified using All‐Patient Refined Diagnosis‐Related Groups. Complex chronic conditions identified using Feudtner and colleagues set of International Classification of Diseases, 9th Revision, Clinical Modification codes. Gastrointestinal devices include gastrostomy, gastrojejunostomy, colostomy. Respiratory devices include tracheostomy, noninvasive positive pressure, ventilator.
Most common reason for admission*
Cystic fibrosis	10.7%
Respiratory system diagnosis with ventilator support 96+ hours	5.5%
Malfunction, reaction, and complication of cardiac or vascular device or procedure	2.8%
Craniotomy except for trauma	2.6%
Major small and large bowel procedures	2.3%
Most common complex chronic condition
Gastrointestinal devices	39.7%
Heart and great vessel malformations	12.8%
Cystic fibrosis	12.5%
Dysrhythmias	11.0%
Respiratory devices	10.7%

Multivariable Analysis of Characteristics Associated With Long LOS

In multivariable analysis, the highest likelihood of long LOS was experienced by children who received care in the ICU (odds ratio [OR]: 3.5, 95% confidence interval [CI]: 3.43.5), who had a respiratory CCC (OR: 2.7, 95% CI: 2.62.7), and who were transferred from another acute care hospital at admission (OR: 2.1, 95% CI: 2.0, 2.1). The likelihood of long LOS was also higher in children <1 year of age (OR: 1.2, 95% CI: 1.21.3), and Hispanic children (OR: 1.1, 95% CI 1.0‐1.10) (Table 3). Similar multivariable findings were observed in sensitivity analysis using the 75th percentile of LOS (4 days) as the model outcome.

Table 3.Multivariable Analysis of the Likelihood of Long Length of Stay 10 Days

Characteristic	Odds Ratio (95% CI) of LOS 10 Days	P Value
NOTE: Abbreviations: CI, confidence interval; LOS, length of stay.
Use of intensive care	3.5 (3.4‐3.5)	<0.001
Transfer from another acute‐care hospital	2.1 (2.0‐2.1)	<0.001
Procedure/surgery	1.8 (1.8‐1.9)	<0.001
Complex chronic condition
Respiratory	2.7 (2.6‐2.7)	<0.001
Gastrointestinal	1.8 (1.8‐1.8)	<0.001
Metabolic	1.7 (1.7‐1.7)	<0.001
Cardiovascular	1.6 (1.5‐1.6)	<0.001
Neonatal	1.5 (1.5‐1.5)	<0.001
Renal	1.4 (1.4‐1.4)	<0.001
Transplant	1.4 (1.4‐1.4)	<0.001
Hematology and immunodeficiency	1.3 (1.3‐1.3)	<0.001
Technology assistance	1.1 (1.1, 1.1)	<0.001
Neuromuscular	0.9 (0.9‐0.9)	<0.001
Congenital or genetic defect	0.8 (0.8‐0.8)	<0.001
Age at admission, y
<1	1.2 (1.2‐1.3)	<0.001
14	0.5 (0.5‐0.5)	<0.001
59	0.6 (0.6‐0.6)	<0.001
1018	0.9 (0.9‐0.9)	<0.001
18+	Reference
Male	0.9 (0.9‐0.9)	<0.001
Race/ethnicity
Non‐Hispanic black	0.9 (0.9‐0.9)	<0.001
Hispanic	1.1 (1.0‐1.1)	<0.001
Asian	1.0 (1.0‐1.1)	0.3
Other	1.1 (1.1‐1.1)	<0.001
Non‐Hispanic white	Reference
Payor
Private	0.9 (0.8 0.9)	<0.001
Other	1.0 (1.0‐1.0)	0.4
Government	Reference
Season
Spring	1.0 (1.0 1.0)	<0.001
Summer	0.9 (0.9‐0.9)	<0.001
Fall	1.0 (0.9‐1.0)	<0.001
Winter	Reference

Variation in the Prevalence of Long LOS Across Children's Hospitals

After controlling for demographic, clinical, and hospital characteristics associated with long LOS, there was significant (P < 0.001) variation in the prevalence of long LOS for CMC across children's hospitals in the cohort (range, 10.3%21.8%) (Figure 1). Twelve (27%) hospitals had a significantly (P < 0.001) higher prevalence of long LOS for their hospitalized CMC, compared to the mean. Eighteen (41%) had a significantly (P < 0.001) lower prevalence of long LOS for their hospitalized CMC. There was also significant variation across hospitals with respect to cost, with 49.7% to 73.7% of all hospital costs of CMC attributed to long LOS hospitalizations. Finally, there was indirect correlation with the prevalence of LOS across hospitals and the hospitals' 30‐day readmission rate ( = 0.3; P = 0.04). As the prevalence of long LOS increased, the readmission rate decreased.

Figure 1

DISCUSSION

The main findings from this study suggest that a small percentage of CMC experiencing long LOS account for the majority of hospital bed days and cost of all hospitalized CMC in children's hospitals. The likelihood of long LOS varies significantly by CMC's age, race/ethnicity, and payor as well as by type and number of chronic conditions. Among CMC with long LOS, the use of gastrointestinal devices such as gastrostomy tubes, as well as congenital heart disease, were highly prevalent. In multivariable analysis, the characteristics most strongly associated with LOS 10 days were use of the ICU, respiratory complex chronic condition, and transfer from another medical facility at admission. After adjusting for these factors, there was significant variation in the prevalence of LOS 10 days for CMC across children's hospitals.

Although it is well known that CMC as a whole have a major impact on resource use in children's hospitals, this study reveals that 15% of hospitalizations of CMC account for 62% of all hospital costs of CMC. That is, a small fraction of hospitalizations of CMC is largely responsible for the significant financial impact of hospital resource use. To date, most clinical efforts and policies striving to reduce hospital use in CMC have focused on avoiding readmissions or index hospital admissions entirely, rather than improving the efficiency of hospital care after admission occurs.[23, 24, 25, 26] In the adult population, the impact of long LOS on hospital costs has been recognized, and several Medicare incentive programs have focused on in‐hospital timeliness and efficiency. As a result, LOS in Medicare beneficiaries has decreased dramatically over the past 2 decades.[27, 28, 29, 30] Optimizing the efficiency of hospital care for CMC may be an important goal to pursue, especially with precedent set in the adult literature.

Perhaps the substantial variation across hospitals in the prevalence of long LOS in CMC indicates opportunity to improve the efficiency of their inpatient care. This variation was not due to differences across hospitals' case mix of CMC. Further investigation is needed to determine how much of it is due to differences in quality of care. Clinical practice guidelines for hospital treatment of common illnesses usually exclude CMC. In our clinical experience across 9 children's hospitals, we have experienced varying approaches to setting discharge goals (ie, parameters on how healthy the child needs to be to ensure a successful hospital discharge) for CMC.[31] When the goals are absent or not clearly articulated, they can contribute to a prolonged hospitalization. Some families of CMC report significant issues when working with pediatric hospital staff to assess their child's discharge readiness.[7, 32, 33] In addition, there is significant variation across states and regions in access to and quality of post‐discharge health services (eg, home nursing, postacute care, durable medical equipment).[34, 35] In some areas, many CMC are not actively involved with their primary care physician.[5] These issues might also influence the ability of some children's hospitals to efficiently discharge CMC to a safe and supportive post‐discharge environment. Further examination of hospital outliersthose with the lowest and highest percentage of CMC hospitalizations with long LOSmay reveal opportunities to identify and spread best practices.

The demographic and clinical factors associated with long LOS in the present study, including age, ICU use, and transfer from another hospital, might help hospitals target which CMC have the greatest risk for experiencing long LOS. We found that infants age <1 year had longer LOS when compared with older children. Similar to our findings, younger‐aged children hospitalized with bronchiolitis have longer LOS.[36] Certainly, infants with medical complexity, in general, are a high‐acuity population with the potential for rapid clinical deterioration during an acute illness. Prolonged hospitalization for treatment and stabilization may be expected for many of them. Additional investigation is warranted to examine ICU use in CMC, and whether ICU admission or duration can be safely prevented or abbreviated. Opportunities to assess the quality of transfers into children's hospitals of CMC admitted to outside hospitals may be necessary. A study of pediatric burn patients reported that patients initially stabilized at a facility that was not a burn center and subsequently transferred to a burn center had a longer LOS than patients solely treated at a designated burn center.[37] Furthermore, events during transport itself may adversely impact the stability of an already fragile patient. Interventions to optimize the quality of care provided by transport teams have resulted in decreased LOS at the receiving hospital.[38]

This study's findings should be considered in the context of several limitations. Absent a gold‐standard definition of long LOS, we used the distribution of LOS across patients to inform our methods; LOS at the 90th percentile was selected as long. Although our sensitivity analysis using LOS at the 75th percentile produced similar findings, other cut points in LOS might be associated with different results. The study is not positioned to determine how much of the reported LOS was excessive, unnecessary, or preventable. The study findings may not generalize to types of hospitals not contained in PHIS (eg, nonchildren's hospitals and community hospitals). We did not focus on the impact of a new diagnosis (eg, new chronic illness) or acute in‐hospital event (eg, nosocomial infection) on prolonged LOS; future studies should investigate these clinical events with LOS.

PHIS does not contain information regarding characteristics that could influence LOS, including the children's social and familial attributes, transportation availability, home equipment needs, and local availability of postacute care facilities. Moreover, PHIS does not contain information about the hospital discharge procedures, process, or personnel across hospitals, which could influence LOS. Future studies on prolonged LOS should consider assessing this information. Because of the large sample size of hospitalizations included, the statistical power for the analyses was strong, rendering it possible that some findings that were statistically significant might have modest clinical significance (eg, relationship of Hispanic ethnicity with prolonged LOS). We could not determine why a positive correlation was not observed between hospitals' long LOS prevalence and their percentage of cost associated with long LOS; future studies should investigate the reasons for this finding.

Despite these limitations, the findings of the present study highlight the significance of long LOS in hospitalized CMC. These long hospitalizations account for a significant proportion of all hospital costs for this important population of children. The prevalence of long LOS for CMC varies considerably across children's hospitals, even after accounting for the case mix. Efforts to curtail hospital resource use and costs for CMC may benefit from focus on long LOS.

Researchers from the Pediatric Research in Inpatient Settings (PRIS) network, an open pediatric hospitalist research network,[1] have identified inpatient pediatric medical and surgical conditions considered high priority for quality improvement (QI) initiatives and/or comparative effectiveness research based on prevalence, cost, and interhospital variation in resource utilization.[2] One approach for improving the quality of care within hospitals is to operationalize evidence‐based guidelines into practice.[3] Although guidelines may be used by individual clinicians, systematic adoption by hospitals into clinical workflow has the potential to influence providers to adhere to evidence‐based care, reduce unwarranted variation, and ultimately improve patient outcomes.[3, 4, 5, 6]

There are critical appraisal tools to measure the methodological quality, as defined by the Institute of Medicine (IOM) and others in their guidelines.[7, 8, 9, 10, 11, 12] One such validated tool is the AGREE II instrument, created by the AGREE (Appraisal of Guidelines for REsearch and Evaluation) collaboration.[13, 14] It defines methodological quality as the confidence that the biases linked to the rigor of development, presentation, and applicability of a clinical practice guideline have been minimized and that each step of the development process is clearly reported.[13]

The objective of our study was to rate the methodological quality of national guidelines for 20 of the PRIS priority pediatric inpatient conditions.[2] Our intent in pursuing this project was 2‐fold: first, to inform pediatric inpatient QI initiatives, and second, to call out priority pediatric inpatient conditions for which high methodological‐quality guidelines are currently lacking.

METHODS

The study methods involved (1) prioritizing pediatric inpatient conditions, (2) identifying national guidelines for the priority conditions, and (3) rating the methodological quality of available guidelines. This study was considered nonhuman‐subject research (A. Johnson, personal e‐mail communication, November 14, 2012), and the original prioritization study was deemed exempt from review by the institutional review board of the Children's Hospital of Philadelphia under 45 CFR 46.102(f).[2]

RESULTS

The librarian's search retrieved 2869 potential results (Figure 1). Seventeen guidelines met inclusion criteria for 13 of the 20 priority conditions. Seven conditions did not have national guidelines meeting inclusion criteria. Table 1 displays the 20 medical and surgical conditions on the modified PRIS prioritization list, including overall guideline scoring, recommendation scores, and kappa results for each guideline. The highest methodological‐quality guidelines were for asthma,[20] tonsillectomy,[21] and bronchiolitis[22] (mean overall rating 7, 6.5, and 6.5, respectively). The lowest methodological‐quality guidelines were for 2 sickle cell disease guidelines[23, 24] and 1 dental caries guideline[25] (mean overall rating 4, 3.5, and 3, respectively). Seven guidelines were rated as high overall quality, and 10 guidelines were rated as moderate overall quality. Eight of the 17 guidelines[20, 21, 22, 26, 27, 28, 29, 30] were recommended for use in the pediatric inpatient setting without modification by both reviewers. Two guidelines (for dental caries[25] and sickle cell[23]) were not recommended for use by 1 reviewer.

Figure 1

As an example of scoring, a national guideline for asthma had high overall scores (7 from each reviewer) and high scores across most AGREE II subcomponents. The guideline was found by both reviewers to be systematic in describing guideline development with clearly stated recommendations linked to the available evidence (including strengths and limitations) and implementation considerations.[20] Conversely, a national guideline for sickle cell disease had moderate overall scores (scores of 3 and 4) and low‐moderate scores across the majority of the subcomponent items.[23] The reviewers believe that this guideline would have been strengthened by increased transparency in guideline development, discussion of the evidence surrounding recommendations, and discussion of implementation factors. A table with detailed scoring of each guideline is available (see Supporting Information, Table 3, in the online version of this article).

Agreement between the 2 raters was almost perfect,[19] with an overall boot‐strapped weighted kappa of 0.83 (95% confidence interval 0.780.87) across 850 scores. There were no discrepancies between reviewers in overall scoring requiring consensus scoring.

DISCUSSION

Using a modified version of a published prioritization list for inpatient pediatric conditions, we found national guidelines for 13 of 20 conditions with high prevalence, cost, and interhospital variation in resource utilization. Seven conditions had no national guidelines published within the past 10 years applicable for use in the pediatric inpatient setting. Of 17 guidelines for 13 conditions, 10 had moderate and 7 had high methodological quality.

Our findings add to the literature describing methodological quality of guidelines. Many publications focus on the methodological quality of guidelines as a group and use a standardized instrument (eg, the AGREE II tool) to rate within domains (eg, domain 1: scope and purpose) across guidelines in an effort to encourage improvement in developing and reporting in guidelines.[31, 32] Our study differs in that we chose to focus on the overall quality rating of individual guidelines for specific prioritized conditions to allow hospitals to guide QI initiatives. One study that had a similar aim to ours surveyed Dutch pediatricians to select priority conditions and used the AGREE II tool to rate 17 guidelines, recommending 14 for use in the Netherlands.[33]

Identifying high methodological‐quality guidelines is only 1 in a series of steps prior to successful guideline implementation in hospitals. Other aspects of guidelines, including the strength of the evidence (eg, from randomized controlled trials) and subsequent force and clarity (eg, use of must instead of consider) of recommendations, may affect clinician or patient adherence, work processes, and ultimately patient outcomes. Strong evidence should translate into forceful and clear recommendations. Authors with the Yale Guideline Recommendation Corpus describe significant variation in reporting of guideline recommendations, and further studies have shown that the force and clarity of a recommendation is associated with adherence rates.[34, 35, 36, 37] Unfortunately, current guideline appraisal tools lack the means to score the strength of evidence, and force and clarity of recommendations.[10]

Implementation science demonstrates that there are many important factors in translating best practice into improvements in clinical care. In addition to implementation considerations such as adherence, patient preferences, and work processes, variability in methodological quality, strength of evidence, and force and clarity of recommendations may be additional reasons why evidence for the impact of guidelines on patient outcomes remains mixed in the literature.[38] One recent study found that adherence to antibiotics recommended within a national pediatric community‐acquired pneumonia guideline, which had a high methodological‐quality score in our study, did not change hospital length of stay or readmissions.[29, 39] There are several possible interpretations for this. Recommendations may not have been based upon strong evidence, research methodology assessing how adherence to recommendations impacts patient outcomes may have been limited, or the outcomes measured in current studies (such as readmission) are not the outcomes that may be improved by adherence to these recommendations (such as decreasing antimicrobial resistance). These are important considerations when hospitals are incorporating recommendations from guidelines into practice. Hospitals should assess the multiple aspects of guidelines, including methodological quality, which our study helps to identify, strength of evidence, and force and clarity of recommendations, as well as adherence, patient preferences, work processes, and key outcome measures when implementing guidelines into clinical practice. A study utilizing a robust QI methodology demonstrated that clinician adherence to several elements in an asthma guideline, which also had a high methodological‐quality score in our study, led to a significant decrease in 6‐month hospital and emergency department readmission for asthma.[6, 20]

Our study also highlights that several pediatric conditions with high prevalence, cost, and interhospital resource utilization variation lack recent national pediatric guidelines applicable to the inpatient setting. If strong evidence exists for these priority conditions, professional societies should create high methodological‐quality guidelines with strong and clear recommendations. If evidence is lacking for these priority conditions, then investigators should focus on generating research in these areas.

There are several limitations to this study. The AGREE II tool does not have a mechanism to measure the strength of evidence used in a guideline. Methodological quality of a guideline alone may not translate into improved outcomes. Conditions may have national guidelines published before 2002, institution‐specific or international guidelines, or adult guidelines that might be amenable to use in the pediatric inpatient setting but were not included in this study. Several conditions on the prioritization list are broad in nature (eg, dehydration) and may not be amenable to the creation of guidelines. Other conditions on the prioritization list (eg, chemotherapy or cellulitis) may have useful guidelines within the context of specific conditions (eg, acute lymphoblastic leukemia) or for specific organisms (eg, methicillin‐resistant Staphylococcus aureus). We elected to exclude these narrower guidelines to focus on broad and comprehensive guidelines applicable to a wider range of clinical situations. Additionally, although use of a validated tool attempts to objectively guide ratings, the rating of quality is to some degree subjective. Finally, our study used a previously published prioritization list using data from children's hospitals, and the list likely under‐represents conditions commonly managed in community hospitals (eg, hyperbilirubinemia).[2] Exclusion of these conditions was not reflective of importance or quality of available national guidelines.

CONCLUSIONS

Our study adds to recent publications on the need to prioritize conditions for QI in children's hospitals. We identified a group of moderate to high methodological‐quality national guidelines for pediatric inpatient conditions with high prevalence, cost, and variation in interhospital resource utilization. Not all prioritized conditions have national high methodological‐quality guidelines available. Hospitals should prioritize conditions with high methodological‐quality guidelines to allocate resources for QI initiatives. Professional societies should focus their efforts on producing methodologically sound guidelines for prioritized conditions currently lacking high‐quality guidelines if sufficient evidence exists.

Disclosures

Sanjay Mahant, Ron Keren, and Raj Srivastava are all Executive Council members of the Pediatric Research in Inpatient Settings (PRIS) Network. PRIS, Sanjay Mahant, Ron Keren, and Raj Srivastava are all supported by grants from the Children's Hospital Association. Sanjay Mahant is also supported by research grants from the Canadian Institute of Health Research and Physician Services Incorporated. Ron Keren and Raj Srivastava also serve as medical legal consultants. The remaining authors have no financial relationships relevant to this article to disclose.

Researchers from the Pediatric Research in Inpatient Settings (PRIS) network, an open pediatric hospitalist research network,[1] have identified inpatient pediatric medical and surgical conditions considered high priority for quality improvement (QI) initiatives and/or comparative effectiveness research based on prevalence, cost, and interhospital variation in resource utilization.[2] One approach for improving the quality of care within hospitals is to operationalize evidence‐based guidelines into practice.[3] Although guidelines may be used by individual clinicians, systematic adoption by hospitals into clinical workflow has the potential to influence providers to adhere to evidence‐based care, reduce unwarranted variation, and ultimately improve patient outcomes.[3, 4, 5, 6]

There are critical appraisal tools to measure the methodological quality, as defined by the Institute of Medicine (IOM) and others in their guidelines.[7, 8, 9, 10, 11, 12] One such validated tool is the AGREE II instrument, created by the AGREE (Appraisal of Guidelines for REsearch and Evaluation) collaboration.[13, 14] It defines methodological quality as the confidence that the biases linked to the rigor of development, presentation, and applicability of a clinical practice guideline have been minimized and that each step of the development process is clearly reported.[13]

The objective of our study was to rate the methodological quality of national guidelines for 20 of the PRIS priority pediatric inpatient conditions.[2] Our intent in pursuing this project was 2‐fold: first, to inform pediatric inpatient QI initiatives, and second, to call out priority pediatric inpatient conditions for which high methodological‐quality guidelines are currently lacking.

METHODS

The study methods involved (1) prioritizing pediatric inpatient conditions, (2) identifying national guidelines for the priority conditions, and (3) rating the methodological quality of available guidelines. This study was considered nonhuman‐subject research (A. Johnson, personal e‐mail communication, November 14, 2012), and the original prioritization study was deemed exempt from review by the institutional review board of the Children's Hospital of Philadelphia under 45 CFR 46.102(f).[2]

RESULTS

The librarian's search retrieved 2869 potential results (Figure 1). Seventeen guidelines met inclusion criteria for 13 of the 20 priority conditions. Seven conditions did not have national guidelines meeting inclusion criteria. Table 1 displays the 20 medical and surgical conditions on the modified PRIS prioritization list, including overall guideline scoring, recommendation scores, and kappa results for each guideline. The highest methodological‐quality guidelines were for asthma,[20] tonsillectomy,[21] and bronchiolitis[22] (mean overall rating 7, 6.5, and 6.5, respectively). The lowest methodological‐quality guidelines were for 2 sickle cell disease guidelines[23, 24] and 1 dental caries guideline[25] (mean overall rating 4, 3.5, and 3, respectively). Seven guidelines were rated as high overall quality, and 10 guidelines were rated as moderate overall quality. Eight of the 17 guidelines[20, 21, 22, 26, 27, 28, 29, 30] were recommended for use in the pediatric inpatient setting without modification by both reviewers. Two guidelines (for dental caries[25] and sickle cell[23]) were not recommended for use by 1 reviewer.

Figure 1

As an example of scoring, a national guideline for asthma had high overall scores (7 from each reviewer) and high scores across most AGREE II subcomponents. The guideline was found by both reviewers to be systematic in describing guideline development with clearly stated recommendations linked to the available evidence (including strengths and limitations) and implementation considerations.[20] Conversely, a national guideline for sickle cell disease had moderate overall scores (scores of 3 and 4) and low‐moderate scores across the majority of the subcomponent items.[23] The reviewers believe that this guideline would have been strengthened by increased transparency in guideline development, discussion of the evidence surrounding recommendations, and discussion of implementation factors. A table with detailed scoring of each guideline is available (see Supporting Information, Table 3, in the online version of this article).

Agreement between the 2 raters was almost perfect,[19] with an overall boot‐strapped weighted kappa of 0.83 (95% confidence interval 0.780.87) across 850 scores. There were no discrepancies between reviewers in overall scoring requiring consensus scoring.

DISCUSSION

Using a modified version of a published prioritization list for inpatient pediatric conditions, we found national guidelines for 13 of 20 conditions with high prevalence, cost, and interhospital variation in resource utilization. Seven conditions had no national guidelines published within the past 10 years applicable for use in the pediatric inpatient setting. Of 17 guidelines for 13 conditions, 10 had moderate and 7 had high methodological quality.

Our findings add to the literature describing methodological quality of guidelines. Many publications focus on the methodological quality of guidelines as a group and use a standardized instrument (eg, the AGREE II tool) to rate within domains (eg, domain 1: scope and purpose) across guidelines in an effort to encourage improvement in developing and reporting in guidelines.[31, 32] Our study differs in that we chose to focus on the overall quality rating of individual guidelines for specific prioritized conditions to allow hospitals to guide QI initiatives. One study that had a similar aim to ours surveyed Dutch pediatricians to select priority conditions and used the AGREE II tool to rate 17 guidelines, recommending 14 for use in the Netherlands.[33]

Identifying high methodological‐quality guidelines is only 1 in a series of steps prior to successful guideline implementation in hospitals. Other aspects of guidelines, including the strength of the evidence (eg, from randomized controlled trials) and subsequent force and clarity (eg, use of must instead of consider) of recommendations, may affect clinician or patient adherence, work processes, and ultimately patient outcomes. Strong evidence should translate into forceful and clear recommendations. Authors with the Yale Guideline Recommendation Corpus describe significant variation in reporting of guideline recommendations, and further studies have shown that the force and clarity of a recommendation is associated with adherence rates.[34, 35, 36, 37] Unfortunately, current guideline appraisal tools lack the means to score the strength of evidence, and force and clarity of recommendations.[10]

Implementation science demonstrates that there are many important factors in translating best practice into improvements in clinical care. In addition to implementation considerations such as adherence, patient preferences, and work processes, variability in methodological quality, strength of evidence, and force and clarity of recommendations may be additional reasons why evidence for the impact of guidelines on patient outcomes remains mixed in the literature.[38] One recent study found that adherence to antibiotics recommended within a national pediatric community‐acquired pneumonia guideline, which had a high methodological‐quality score in our study, did not change hospital length of stay or readmissions.[29, 39] There are several possible interpretations for this. Recommendations may not have been based upon strong evidence, research methodology assessing how adherence to recommendations impacts patient outcomes may have been limited, or the outcomes measured in current studies (such as readmission) are not the outcomes that may be improved by adherence to these recommendations (such as decreasing antimicrobial resistance). These are important considerations when hospitals are incorporating recommendations from guidelines into practice. Hospitals should assess the multiple aspects of guidelines, including methodological quality, which our study helps to identify, strength of evidence, and force and clarity of recommendations, as well as adherence, patient preferences, work processes, and key outcome measures when implementing guidelines into clinical practice. A study utilizing a robust QI methodology demonstrated that clinician adherence to several elements in an asthma guideline, which also had a high methodological‐quality score in our study, led to a significant decrease in 6‐month hospital and emergency department readmission for asthma.[6, 20]

Our study also highlights that several pediatric conditions with high prevalence, cost, and interhospital resource utilization variation lack recent national pediatric guidelines applicable to the inpatient setting. If strong evidence exists for these priority conditions, professional societies should create high methodological‐quality guidelines with strong and clear recommendations. If evidence is lacking for these priority conditions, then investigators should focus on generating research in these areas.

There are several limitations to this study. The AGREE II tool does not have a mechanism to measure the strength of evidence used in a guideline. Methodological quality of a guideline alone may not translate into improved outcomes. Conditions may have national guidelines published before 2002, institution‐specific or international guidelines, or adult guidelines that might be amenable to use in the pediatric inpatient setting but were not included in this study. Several conditions on the prioritization list are broad in nature (eg, dehydration) and may not be amenable to the creation of guidelines. Other conditions on the prioritization list (eg, chemotherapy or cellulitis) may have useful guidelines within the context of specific conditions (eg, acute lymphoblastic leukemia) or for specific organisms (eg, methicillin‐resistant Staphylococcus aureus). We elected to exclude these narrower guidelines to focus on broad and comprehensive guidelines applicable to a wider range of clinical situations. Additionally, although use of a validated tool attempts to objectively guide ratings, the rating of quality is to some degree subjective. Finally, our study used a previously published prioritization list using data from children's hospitals, and the list likely under‐represents conditions commonly managed in community hospitals (eg, hyperbilirubinemia).[2] Exclusion of these conditions was not reflective of importance or quality of available national guidelines.

CONCLUSIONS

Our study adds to recent publications on the need to prioritize conditions for QI in children's hospitals. We identified a group of moderate to high methodological‐quality national guidelines for pediatric inpatient conditions with high prevalence, cost, and variation in interhospital resource utilization. Not all prioritized conditions have national high methodological‐quality guidelines available. Hospitals should prioritize conditions with high methodological‐quality guidelines to allocate resources for QI initiatives. Professional societies should focus their efforts on producing methodologically sound guidelines for prioritized conditions currently lacking high‐quality guidelines if sufficient evidence exists.

Disclosures

Sanjay Mahant, Ron Keren, and Raj Srivastava are all Executive Council members of the Pediatric Research in Inpatient Settings (PRIS) Network. PRIS, Sanjay Mahant, Ron Keren, and Raj Srivastava are all supported by grants from the Children's Hospital Association. Sanjay Mahant is also supported by research grants from the Canadian Institute of Health Research and Physician Services Incorporated. Ron Keren and Raj Srivastava also serve as medical legal consultants. The remaining authors have no financial relationships relevant to this article to disclose.

Researchers from the Pediatric Research in Inpatient Settings (PRIS) network, an open pediatric hospitalist research network,[1] have identified inpatient pediatric medical and surgical conditions considered high priority for quality improvement (QI) initiatives and/or comparative effectiveness research based on prevalence, cost, and interhospital variation in resource utilization.[2] One approach for improving the quality of care within hospitals is to operationalize evidence‐based guidelines into practice.[3] Although guidelines may be used by individual clinicians, systematic adoption by hospitals into clinical workflow has the potential to influence providers to adhere to evidence‐based care, reduce unwarranted variation, and ultimately improve patient outcomes.[3, 4, 5, 6]

There are critical appraisal tools to measure the methodological quality, as defined by the Institute of Medicine (IOM) and others in their guidelines.[7, 8, 9, 10, 11, 12] One such validated tool is the AGREE II instrument, created by the AGREE (Appraisal of Guidelines for REsearch and Evaluation) collaboration.[13, 14] It defines methodological quality as the confidence that the biases linked to the rigor of development, presentation, and applicability of a clinical practice guideline have been minimized and that each step of the development process is clearly reported.[13]

The objective of our study was to rate the methodological quality of national guidelines for 20 of the PRIS priority pediatric inpatient conditions.[2] Our intent in pursuing this project was 2‐fold: first, to inform pediatric inpatient QI initiatives, and second, to call out priority pediatric inpatient conditions for which high methodological‐quality guidelines are currently lacking.

METHODS

The study methods involved (1) prioritizing pediatric inpatient conditions, (2) identifying national guidelines for the priority conditions, and (3) rating the methodological quality of available guidelines. This study was considered nonhuman‐subject research (A. Johnson, personal e‐mail communication, November 14, 2012), and the original prioritization study was deemed exempt from review by the institutional review board of the Children's Hospital of Philadelphia under 45 CFR 46.102(f).[2]

RESULTS

The librarian's search retrieved 2869 potential results (Figure 1). Seventeen guidelines met inclusion criteria for 13 of the 20 priority conditions. Seven conditions did not have national guidelines meeting inclusion criteria. Table 1 displays the 20 medical and surgical conditions on the modified PRIS prioritization list, including overall guideline scoring, recommendation scores, and kappa results for each guideline. The highest methodological‐quality guidelines were for asthma,[20] tonsillectomy,[21] and bronchiolitis[22] (mean overall rating 7, 6.5, and 6.5, respectively). The lowest methodological‐quality guidelines were for 2 sickle cell disease guidelines[23, 24] and 1 dental caries guideline[25] (mean overall rating 4, 3.5, and 3, respectively). Seven guidelines were rated as high overall quality, and 10 guidelines were rated as moderate overall quality. Eight of the 17 guidelines[20, 21, 22, 26, 27, 28, 29, 30] were recommended for use in the pediatric inpatient setting without modification by both reviewers. Two guidelines (for dental caries[25] and sickle cell[23]) were not recommended for use by 1 reviewer.

Figure 1

As an example of scoring, a national guideline for asthma had high overall scores (7 from each reviewer) and high scores across most AGREE II subcomponents. The guideline was found by both reviewers to be systematic in describing guideline development with clearly stated recommendations linked to the available evidence (including strengths and limitations) and implementation considerations.[20] Conversely, a national guideline for sickle cell disease had moderate overall scores (scores of 3 and 4) and low‐moderate scores across the majority of the subcomponent items.[23] The reviewers believe that this guideline would have been strengthened by increased transparency in guideline development, discussion of the evidence surrounding recommendations, and discussion of implementation factors. A table with detailed scoring of each guideline is available (see Supporting Information, Table 3, in the online version of this article).

Agreement between the 2 raters was almost perfect,[19] with an overall boot‐strapped weighted kappa of 0.83 (95% confidence interval 0.780.87) across 850 scores. There were no discrepancies between reviewers in overall scoring requiring consensus scoring.

DISCUSSION

Using a modified version of a published prioritization list for inpatient pediatric conditions, we found national guidelines for 13 of 20 conditions with high prevalence, cost, and interhospital variation in resource utilization. Seven conditions had no national guidelines published within the past 10 years applicable for use in the pediatric inpatient setting. Of 17 guidelines for 13 conditions, 10 had moderate and 7 had high methodological quality.

Our findings add to the literature describing methodological quality of guidelines. Many publications focus on the methodological quality of guidelines as a group and use a standardized instrument (eg, the AGREE II tool) to rate within domains (eg, domain 1: scope and purpose) across guidelines in an effort to encourage improvement in developing and reporting in guidelines.[31, 32] Our study differs in that we chose to focus on the overall quality rating of individual guidelines for specific prioritized conditions to allow hospitals to guide QI initiatives. One study that had a similar aim to ours surveyed Dutch pediatricians to select priority conditions and used the AGREE II tool to rate 17 guidelines, recommending 14 for use in the Netherlands.[33]

Identifying high methodological‐quality guidelines is only 1 in a series of steps prior to successful guideline implementation in hospitals. Other aspects of guidelines, including the strength of the evidence (eg, from randomized controlled trials) and subsequent force and clarity (eg, use of must instead of consider) of recommendations, may affect clinician or patient adherence, work processes, and ultimately patient outcomes. Strong evidence should translate into forceful and clear recommendations. Authors with the Yale Guideline Recommendation Corpus describe significant variation in reporting of guideline recommendations, and further studies have shown that the force and clarity of a recommendation is associated with adherence rates.[34, 35, 36, 37] Unfortunately, current guideline appraisal tools lack the means to score the strength of evidence, and force and clarity of recommendations.[10]

Implementation science demonstrates that there are many important factors in translating best practice into improvements in clinical care. In addition to implementation considerations such as adherence, patient preferences, and work processes, variability in methodological quality, strength of evidence, and force and clarity of recommendations may be additional reasons why evidence for the impact of guidelines on patient outcomes remains mixed in the literature.[38] One recent study found that adherence to antibiotics recommended within a national pediatric community‐acquired pneumonia guideline, which had a high methodological‐quality score in our study, did not change hospital length of stay or readmissions.[29, 39] There are several possible interpretations for this. Recommendations may not have been based upon strong evidence, research methodology assessing how adherence to recommendations impacts patient outcomes may have been limited, or the outcomes measured in current studies (such as readmission) are not the outcomes that may be improved by adherence to these recommendations (such as decreasing antimicrobial resistance). These are important considerations when hospitals are incorporating recommendations from guidelines into practice. Hospitals should assess the multiple aspects of guidelines, including methodological quality, which our study helps to identify, strength of evidence, and force and clarity of recommendations, as well as adherence, patient preferences, work processes, and key outcome measures when implementing guidelines into clinical practice. A study utilizing a robust QI methodology demonstrated that clinician adherence to several elements in an asthma guideline, which also had a high methodological‐quality score in our study, led to a significant decrease in 6‐month hospital and emergency department readmission for asthma.[6, 20]

Our study also highlights that several pediatric conditions with high prevalence, cost, and interhospital resource utilization variation lack recent national pediatric guidelines applicable to the inpatient setting. If strong evidence exists for these priority conditions, professional societies should create high methodological‐quality guidelines with strong and clear recommendations. If evidence is lacking for these priority conditions, then investigators should focus on generating research in these areas.

There are several limitations to this study. The AGREE II tool does not have a mechanism to measure the strength of evidence used in a guideline. Methodological quality of a guideline alone may not translate into improved outcomes. Conditions may have national guidelines published before 2002, institution‐specific or international guidelines, or adult guidelines that might be amenable to use in the pediatric inpatient setting but were not included in this study. Several conditions on the prioritization list are broad in nature (eg, dehydration) and may not be amenable to the creation of guidelines. Other conditions on the prioritization list (eg, chemotherapy or cellulitis) may have useful guidelines within the context of specific conditions (eg, acute lymphoblastic leukemia) or for specific organisms (eg, methicillin‐resistant Staphylococcus aureus). We elected to exclude these narrower guidelines to focus on broad and comprehensive guidelines applicable to a wider range of clinical situations. Additionally, although use of a validated tool attempts to objectively guide ratings, the rating of quality is to some degree subjective. Finally, our study used a previously published prioritization list using data from children's hospitals, and the list likely under‐represents conditions commonly managed in community hospitals (eg, hyperbilirubinemia).[2] Exclusion of these conditions was not reflective of importance or quality of available national guidelines.

CONCLUSIONS

Our study adds to recent publications on the need to prioritize conditions for QI in children's hospitals. We identified a group of moderate to high methodological‐quality national guidelines for pediatric inpatient conditions with high prevalence, cost, and variation in interhospital resource utilization. Not all prioritized conditions have national high methodological‐quality guidelines available. Hospitals should prioritize conditions with high methodological‐quality guidelines to allocate resources for QI initiatives. Professional societies should focus their efforts on producing methodologically sound guidelines for prioritized conditions currently lacking high‐quality guidelines if sufficient evidence exists.

Disclosures

Sanjay Mahant, Ron Keren, and Raj Srivastava are all Executive Council members of the Pediatric Research in Inpatient Settings (PRIS) Network. PRIS, Sanjay Mahant, Ron Keren, and Raj Srivastava are all supported by grants from the Children's Hospital Association. Sanjay Mahant is also supported by research grants from the Canadian Institute of Health Research and Physician Services Incorporated. Ron Keren and Raj Srivastava also serve as medical legal consultants. The remaining authors have no financial relationships relevant to this article to disclose.