Amanda C. Schondelmeyer

Importance: In the US, states enacted nonpharmaceutical interventions, including school closure, to reduce the spread of coronavirus disease 2019 (COVID-19). All 50 states closed schools in March 2020 despite uncertainty if school closure would be effective. Objective: To determine if school closure and its timing were associated with decreased COVID-19 incidence and mortality. Design, Setting, and Participants: US population-based observational study conducted between March 9, 2020, and May 7, 2020, using interrupted time series analyses incorporating a lag period to allow for potential policy-associated changes to occur. To isolate the association of school closure with outcomes, state-level nonpharmaceutical interventions and attributes were included in negative binomial regression models. States were examined in quartiles based on state-level COVID-19 cumulative incidence per 100 000 residents at the time of school closure. Models were used to derive the estimated absolute differences between schools that closed and schools that remained open as well as the number of cases and deaths if states had closed schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile. Exposures: Closure of primary and secondary schools. Main Outcomes and Measures: COVID-19 daily incidence and mortality per 100 000 residents. Results: COVID-19 cumulative incidence in states at the time of school closure ranged from 0 to 14.75 cases per 100 000 population. School closure was associated with a significant decline in the incidence of COVID-19 (adjusted relative change per week, -62% [95% CI, -71% to -49%]) and mortality (adjusted relative change per week, -58% [95% CI, -68% to -46%]). Both of these associations were largest in states with low cumulative incidence of COVID-19 at the time of school closure. For example, states with the lowest incidence of COVID-19 had a -72% (95% CI, -79% to -62%) relative change in incidence compared with -49% (95% CI, -62% to -33%) for those states with the highest cumulative incidence. In a model derived from this analysis, it was estimated that closing schools when the cumulative incidence of COVID-19 was in the lowest quartile compared with the highest quartile was associated with 128.7 fewer cases per 100 000 population over 26 days and with 1.5 fewer deaths per 100 000 population over 16 days. Conclusions and Relevance: Between March 9, 2020, and May 7, 2020, school closure in the US was temporally associated with decreased COVID-19 incidence and mortality; states that closed schools earlier, when cumulative incidence of COVID-19 was low, had the largest relative reduction in incidence and mortality. However, it remains possible that some of the reduction may have been related to other concurrent nonpharmaceutical interventions.

BACKGROUND AND OBJECTIVES: Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS: Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS: We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09). CONCLUSIONS: Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.

BACKGROUND: Bed capacity management is a critical issue facing hospital administrators, and inefficient discharges impact patient flow throughout the hospital. National recommendations include a focus on providing care that is timely and efficient, but a lack of standardised discharge criteria at our institution contributed to unpredictable discharge timing and lengthy delays. Our objective was to increase the percentage of Hospital Medicine patients discharged within 2 h of meeting criteria from 42% to 80%. METHODS: A multidisciplinary team collaborated to develop medically appropriate discharge criteria for 11 common inpatient diagnoses. Discharge criteria were embedded into electronic medical record (EMR) order sets at admission and could be modified throughout a patient's stay. Nurses placed an EMR time-stamp to signal when patients met all discharge goals. Strategies to improve discharge timeliness emphasised completion of discharge tasks prior to meeting criteria. Interventions focused on buy-in from key team members, pharmacy process redesign, subspecialty consult timeliness and feedback to frontline staff. A P statistical process control chart assessed the impact of interventions over time. Length of stay (LOS) and readmission rates before and after implementation of process measures were compared using the Wilcoxon rank-sum test. RESULTS: The percentage of patients discharged within 2 h significantly improved from 42% to 80% within 18 months. Patients studied had a decrease in median overall LOS (from 1.56 to 1.44 days; p=0.01), without an increase in readmission rates (4.60% to 4.21%; p=0.24). The 12-month rolling average census for the study units increased from 36.4 to 42.9, representing an 18% increase in occupancy. CONCLUSIONS: Through standardising discharge goals and implementation of high-reliability interventions, we reduced LOS without increasing readmission rates.

BACKGROUND: Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE: Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN: Retrospective cross-sectional study in 2013. SETTING: Thirty-three hospitals in the Pediatric Health Information System. PATIENTS: Infants aged ≤56 days with a diagnosis of fever. EXPOSURES: The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS: Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS: We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS: CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

OBJECTIVES: To examine the incidence, mortality, and health care use related to neonatal herpes simplex virus (HSV) infection. METHODS: A retrospective longitudinal cohort study using a multistate Medicaid claims database. We identified neonates hospitalized with HSV infection from 2009 to 2015 by using discharge diagnosis codes and managed them for 6 months after discharge. Incidence rates were corrected for the imperfect sensitivity and specificity of thediagnosis codes for identifying HSV infection. RESULTS: Of 2 107 124 births from 2009 to 2015, 900 neonates were identified with HSV infection, with a corrected incidence rate of 4.5 (95% confidence interval [CI]: 4.2–4.8) per 10 000 births. The yearly disease incidence increased by 56%, from 3.4 (95% CI: 2.8–4.2) per 10 000 births (or 1 in 2941 births) in 2009 to 5.3 (95% CI: 4.6–6.1) per 10 000 births (or 1 in 1886 births) in 2015 (P &amp;lt; .001). Of the 900 neonates with HSV infection, 54 (6.0% [95% CI: 4.4%–7.6%]) died during the index hospitalization; there was no increase in the yearly mortality rate. Of the 692 (81.2%) infants with follow-up data, 316 (45.7%) had an emergency department visit, and 112 (16.2%) had a hospital readmission. Total payments at 6 months amounted to $60 620 431, a median of $87 602 per case of neonatal HSV infection. CONCLUSIONS: We observed an increase in neonatal HSV infection incidence over a recent 7-year period in a Medicaid population. Associated health care use and payments were substantial. Public health interventions targeting disease prevention and early diagnosis are needed.