The pediatric complex chronic conditions (CCC) classification system, developed in 2000, requires revision to accommodate the International Classification of Disease 10th Revision (ICD-10). To update the CCC classification system, we incorporated ICD-9 diagnostic codes that had been either omitted or incorrectly specified in the original system, and then translated between ICD-9 and ICD-10 using General Equivalence Mappings (GEMs). We further reviewed all codes in the ICD-9 and ICD-10 systems to include both diagnostic and procedural codes indicative of technology dependence or organ transplantation. We applied the provisional CCC version 2 (v2) system to death certificate information and 2 databases of health utilization, reviewed the resulting CCC classifications, and corrected any misclassifications. Finally, we evaluated performance of the CCC v2 system by assessing: 1) the stability of the system between ICD-9 and ICD-10 codes using data which included both ICD-9 codes and ICD-10 codes; 2) the year-to-year stability before and after ICD-10 implementation; and 3) the proportions of patients classified as having a CCC in both the v1 and v2 systems. The CCC v2 classification system consists of diagnostic and procedural codes that incorporate a new neonatal CCC category as well as domains of complexity arising from technology dependence or organ transplantation. CCC v2 demonstrated close comparability between ICD-9 and ICD-10 and did not detect significant discontinuity in temporal trends of death in the United States. Compared to the original system, CCC v2 resulted in a 1.0% absolute (10% relative) increase in the number of patients identified as having a CCC in national hospitalization dataset, and a 0.4% absolute (24% relative) increase in a national emergency department dataset. The updated CCC v2 system is comprehensive and multidimensional, and provides a necessary update to accommodate widespread implementation of ICD-10.

Research from JAMA Pediatrics — Prioritization of Comparative Effectiveness Research Topics in Hospital Pediatrics

Background and Purpose— Studies suggest that women with stroke are investigated less aggressively and receive tissue plasminogen activator less frequently than men. We tested whether gender differences in the investigation, treatment, and outcome of stroke are due to confounding factors. Methods— Gender differences in the use of investigations, trial enrollment, treatment with intravenous tissue plasminogen activator, and in-hospital outcomes were examined in data from our prospective registry using multivariate analysis to adjust for age, prestroke functional status, stroke subtype and severity, and atrial fibrillation. Results— Of 2725 consecutive hospitalized patients (1996 to 2006), 88% had ischemic stroke and 48% were women. Women were older (median age, 77 versus 70 years), had more severe strokes, and were less likely to be independent prestroke (78% versus 87%) compared with men (all P <0.001). The proportion of women, but not men, aged ≥80 years, increased significantly between 1996 to 1997 and 2005 to 2006. After adjustment for confounding, women were less likely to have infratentorial strokes (OR, 0.78; 95% CI, 0.62 to 0.97), be able to walk unaided on admission (OR, 0.69; 95% CI, 0.54 to 0.87), be treated with tissue plasminogen activator (OR, 0.51; 95% CI, 0.35 to 0.72), experience pneumonia (OR, 0.38; 95% CI, 0.26 to 0.55), achieve a discharge Barthel Index of ≥95 (OR, 0.75; 95% CI, 0.61 to 0.94, and were more likely to experience a urinary tract infection (OR, 2.06; 95% CI, 1.61 to 2.64). There was no gender difference in adjusted use of investigations. Conclusion— The majority of the gender differences in stroke were explained by confounding. More research is required to understand gender differences in stroke pathophysiology and the utilization of thrombolytic therapy.

Objectives: Polypharmacy is common in hospitalized children in the United States and has been identified as a major risk factor for exposure to potential drug–drug interactions. Little is known about the characteristics and prevalence of exposure of pediatric patients to polypharmacy and potential drug–drug interactions in PICUs. Design: Retrospective cohort study using the Pediatric Health Information System database. Setting: Forty-two freestanding children’s hospitals throughout the United States. Patients: A total of 54,549 patients less than 18 years old cared for in PICUs in 2011. Patients in neonatal ICUs were not included. Measurements and Main Results: PICU patients were on average exposed to 10 distinct drugs each hospital day and to 20 drugs cumulatively during their hospitalization. Seventy-five percent of patients were exposed to greater than or equal to one potential drug–drug interaction regardless of severity level, 6% to greater than or equal to one contraindicated potential drug–drug interaction, 69% to greater than or equal to one major potential drug–drug interaction, 57% to greater than or equal to one moderate potential drug–drug interaction, 19% to greater than or equal to one minor potential drug–drug interaction. Potential drug–drug interaction exposures were significantly associated with specific diagnoses (p < 0.001), presence of complex chronic conditions (p < 0.001), increasing number of total distinct drugs used (p < 0.001), increasing length of stay in PICU (p < 0.001), and white race (p < 0.001). Conclusions: Many PICU patients are exposed to substantial polypharmacy and potential drug–drug interactions. Future research should identify the risk of adverse drug events following specific potential drug–drug interaction exposures, especially the risk of adverse drug events due to multiple potential drug–drug interaction exposures, and determine the probability and magnitude of the actual harm (if any) for each specific potential drug–drug interaction, especially for multiple potential drug–drug interaction exposures.