Objective-To compare the prevalence, resource utilization, and mortality for pediatric severe sepsis identified using two established identification strategies. Design-Observational cohort study from 2004-2012.Setting-Forty-four pediatric hospitals contributing data to the Pediatric Health Information Systems database.Patients-Children ≤18 years of age.Measurements and Main Results-We identified patients with severe sepsis or septic shock by using two International Classification of Diseases, 9 th edition-Clinical Modification (ICD9-CM) based coding strategies: 1) combinations of ICD9-CM codes for infection plus organ dysfunction (combination code cohort); 2) ICD9-CM codes for severe sepsis and septic shock (sepsis code cohort). Outcomes included prevalence of severe sepsis, as well as hospital and intensive care unit (ICU) length of stay (LOS), and mortality. Outcomes were compared between the two cohorts examining aggregate differences over the study period and trends over time. The combination code cohort identified, 176,124 hospitalizations (3.1% of all hospitalizations), while the sepsis code cohort identified 25,236 hospitalizations (0.45%), a 7-fold difference. Between 2004 and 2012, the prevalence of sepsis increased from 3.7% to 4.4% using the combination code cohort and from 0.4% to 0.7% using the sepsis code cohort (p<0.001 for trend in each cohort). LOS (hospital and ICU) and costs decreased in both cohorts over the study period (p<0.001). Overall hospital mortality was higher in the sepsis code cohort than the combination code cohort (21.2%,. Over the 9 year study period, there was an absolute reduction in mortality of 10.9% (p<0.001) in the sepsis code cohort and 3.8% (p<0.001) in the combination code cohort.Conclusions-Prevalence of pediatric severe sepsis increased in the studied US children's hospitals over the past 9 years, though resource utilization and mortality decreased. Epidemiologic estimates of pediatric severe sepsis varied up to 7-fold depending on the strategy used for case ascertainment.

Background Substantial care variation occurs in a number of pediatric diseases. Methods We evaluated the variability in health care resource utilization and its association with clinical outcomes among children, aged 1–18 years, hospitalized with community acquired pneumonia (CAP). Each of 29 children’s hospitals contributing data to the Pediatric Hospital Information System was ranked based on the proportion of CAP patients receiving each of 8 diagnostic tests. Primary outcome variable was length of stay (LOS), re-visit to the ED or readmission within 14 days of discharge. Results Of 21,213 children hospitalized with non-severe CAP, median age was 3 years (interquartile range [IQR], 1–6 years). Laboratory testing and antibiotic usage varied widely across hospitals; cephalosporins were the most commonly prescribed antibiotic. There were large differences in the processes of care by age categories. The median LOS was 2 days (IQR, 1–3 days) and differed across hospitals; 25% of hospitals had median LOS >= 3 days. Hospital-level variation occurred in 14-day ED visits and 14-day readmission, ranging from 0.9 to 4.9% and 1.5% to 4.4%, respectively. Increased utilization of diagnostic testing was associated with longer hospital LOS (p=0.036) but not with probability of 14-day readmission (Spearman’s ρ = 0.234; p=0.225). There was an inverse correlation between LOS and 14-day revisit to the ED (ρ=−0.48, p=0.013). Conclusions Wide variability occurred in diagnostic testing for children hospitalized with CAP. Increased diagnostic testing was associated with a longer LOS. Earlier hospital discharge did not correlate with increased 14-day readmission. The precise interaction of increased utilization with longer LOS remains unclear.

Children with medical complexity disproportionately use the majority of ICU resources in children's hospitals. Efforts to improve quality and provide cost-effective care should focus on this population.