Encounters for SI and SA at US children's hospitals increased steadily from 2008 to 2015 and accounted for an increasing percentage of all hospital encounters. Increases were noted across all age groups, with consistent seasonal patterns that persisted over the study period. The growing impact of pediatric mental health disorders has important implications for children's hospitals and health care delivery systems.

Rapid cycle plan-do-study-act methodology, initially focusing on the inclusion of a daily laboratory plan in progress notes, was an effective means to improve laboratory utilization and decrease laboratory charges without adversely affecting other quality measures. Spreading these efforts to different patient populations and laboratory tests could have a demonstrable effect on the value of health care.

Acute gastroenteritis (AGE) remains a major cause of childhood morbidity and mortality in the United States. The routine use of vaccines targeting rotavirus, the most common cause of pediatric AGE, has decreased all-cause AGE emergency department (ED) visits and hospitalizations. 1 However, the burden of pediatric AGE remains substantial. With annual hospitalization rates of 3 to 5 per 1000 US children ,5 years of age, AGE remains among the top 10 reasons for pediatric hospitalization nationwide. 1,2 The financial burden of ED care and hospitalization alone accounts for .$350 million in costs annually. 3 Care for uncomplicated AGE is largely supportive, and guidelines from the American Academy of Pediatrics and other international organizations emphasize conservative management and discourage routine diagnostic testing for AGE, with or without dehydration. 4-6 Yet there continues to be wide variation in AGE management among individual providers and hospitals in the United States and abroad. 7,8 Studies in children with acute respiratory illness show similar variation in care that is associated with important outcome differences, with higher resource utilization linked to higher rates of hospitalization and longer hospital length of stay (LOS), irrespective of the severity of illness. 9,10 Whether similar associations exist between resource utilization and outcomes in children with AGE is largely unexplored. With the use of data from 34 US children' s hospitals, we sought to characterize hospital-level variation in diagnostic testing and hospitalization rates in children with AGE presenting for emergency care. We also examined associations between diagnostic testing and rates of hospitalization. METHODS Study Design and Data Source We conducted a multicenter, retrospective study in children with AGE evaluated at 1 of 34 US children' s hospitals that contribute data to the Pediatric Health Information System (PHIS) administrative database (Children' s Hospital Association, Overland Park, KS). The PHIS database contains patient demographic characteristics and billed

BACKGROUND AND OBJECTIVES: Patient complexity at US children’s hospitals is increasing. Hospitals experience concurrent pressure to reduce length of stay (LOS) and readmissions, yet little is known about how these common measures of resource use and quality have changed over time. Our aim was to examine temporal trends in medical complexity, hospital LOS, and readmissions across a sample of US children’s hospitals. METHODS: Retrospective cohort study of hospitalized patients from 42 children’s hospitals in the Pediatric Health Information System from 2013 to 2017. After excluding deaths, healthy newborns, obstetric care, and low volume service lines, we analyzed trends in medical complexity, LOS, and 14-day all-cause readmissions using generalized linear mixed effects models, adjusting for changes in patient factors and case-mix. RESULTS: Between 2013 and 2017, a total of 3 355 815 discharges were included. Over time, the mean case-mix index and the proportion of hospitalized patients with complex chronic conditions or receiving intensive care increased (P < .001 for all). In adjusted analyses, mean LOS declined 3% (61.1 hours versus 59.3 hours from 2013 to 2017, P < .001), whereas 14-day readmissions were unchanged (7.0% vs 6.9%; P = .03). Reductions in adjusted LOS were noted in both medical and surgical service lines (3.6% and 2.0% decline, respectively; P < .001). CONCLUSIONS: Across US children’s hospitals, adjusted LOS declined whereas readmissions remained stable, suggesting that children’s hospitals are providing more efficient care for an increasingly complex patient population.