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Aronson PL, Thurm C, Alpern ER, Alessandrini EA, Williams DJ, Shah SS, Nigrovic LE, McCulloh RJ, Schondelmeyer A, Tieder JS, Neuman MI. Variation in care of the febrile young infant <90 days in US pediatric emergency departments. Pediatrics 2014; 134:667-77. [PMID: 25266437 DOI: 10.1542/peds.2014-1382] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Paul L Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut;
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Samir S Shah
- Hospital Medicine, and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Russell J McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and
| | | | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Shamszad P, Hall M, Rossano JW, Denfield SW, Knudson JD, Penny DJ, Towbin JA, Cabrera AG. Characteristics and outcomes of heart failure-related intensive care unit admissions in children with cardiomyopathy. J Card Fail 2014; 19:672-7. [PMID: 24125105 DOI: 10.1016/j.cardfail.2013.08.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2012] [Revised: 08/16/2013] [Accepted: 08/16/2013] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The purpose of this study was to describe patient characteristics and outcomes of heart failure (HF)-related intensive care unit (ICU) hospitalizations in children with cardiomyopathy (CM). METHODS AND RESULTS A query of the Pediatric Health Information System database, a large administrative and billing database of 43 tertiary children's hospitals, was performed. A total of 17,309 HF-related ICU hospitalizations from 2005 to 2010 of 14,985 children ≤18 years old were analyzed. Of those, 2,058 (12%) hospitalizations for CM-HF in 1,599 (11%) children were identified. Classification into CM subtypes was not possible owing to database limitations. The number of yearly CM-HF hospitalizations significantly increased during the study period (P = .036). Overall mortality was 11%, and cardiac transplantation occurred in 20% of hospitalizations. Mechanical circulatory support (MCS) was used in 261 (13%) of hospitalizations. Renal failure, MCS, respiratory failure, sepsis, and vasoactive medications were associated with mortality on multivariable analysis. Significant comorbidities associated with these hospitalizations included arrhythmias in 42%, renal failure in 13%, cerebrovascular disease in 6%, and hepatic impairment in 5%. CONCLUSIONS HF-related ICU hospitalizations in children with cardiomyopathy are increasing. These children are at high risk for poor outcomes with an in-hospital mortality of 11%.
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Affiliation(s)
- Pirouz Shamszad
- Department of Pediatrics, Lillie Frank Abercrombie Section of Cardiology, Baylor College of Medicine, Houston, Texas; Department of Pediatrics, The Heart Institute, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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MacVane SH, Tuttle LO, Nicolau DP. Demography and burden of care associated with patients readmitted for urinary tract infection. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2014; 48:517-24. [PMID: 24863498 DOI: 10.1016/j.jmii.2014.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Revised: 04/02/2014] [Accepted: 04/03/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Urinary tract infection (UTI) is one of the most prevalent admission diagnoses in hospital-based clinical practice. Despite its frequency, few data are available regarding its demographics and economic implications. PURPOSE To describe the demography, epidemiology, and burden of care of patients admitted to hospital with UTI and compare these characteristics depending on admission status. METHODS A retrospective cohort study using an administrative database of patients admitted to Hartford Hospital (September 2011-August 2012) with UTI. Patient demographics, hospital characteristics, and total costs of care were examined. RESULTS A total of 2345 unique patients were included. The mean age of the patients was 78 years and 71% were female. Median length of stay and total cost were 5 days and $8326 (interquartile range $5388-$14,179), respectively. A total of 359 patients (16.4%) were readmitted within 30 days, of which 111 patients (5.1%) had UTI on readmission. Only 16.3% of readmitted patients were infected with the same causative pathogen. A significant increase in the incidence of Enterococcus faecalis (1.2% vs. 9.3%; p = 0.046) occurred upon readmission, whereas occurrence of Enterobacteriaceae infection decreased in the readmission group (50.0% vs. 25.6%; p = 0.006), including a lower proportion of Escherichia coli (32.5% vs. 11.6%; p < 0.001). A higher proportion of readmission pathogens were nonsusceptible, including significant changes to cefazolin (24.4% vs. 63.6%; p = 0.004) and cefepime (8.7% vs. 27.6; p = 0.05). CONCLUSION UTI is highly prevalent and is associated with significant utilization of health-care resources among hospitalized patients. These findings, coupled with considerable rates of 30-day readmission, stress the importance of proper diagnosis and treatment.
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Affiliation(s)
- Shawn H MacVane
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | - Lindsay O Tuttle
- Saint Francis Hospital - Research Department, Saint Francis Hospital, Hartford, CT, USA
| | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA; Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA.
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Shiff NJ, Jama S, Boden C, Lix LM. Validation of administrative health data for the pediatric population: a scoping review. BMC Health Serv Res 2014; 14:236. [PMID: 24885035 PMCID: PMC4057929 DOI: 10.1186/1472-6963-14-236] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Accepted: 05/15/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this research was to perform a scoping review of published literature on the validity of administrative health data for ascertaining health conditions in the pediatric population (≤20 years). METHODS A comprehensive search of OVID Medline (1946 - present), CINAHL (1937 - present) and EMBASE (1947 - present) was conducted. Characteristics of validation studies that were abstracted included the study population, health condition, topic of the validation (e.g., single diagnosis code versus case-finding algorithm), administrative and validation data sources. Inter-rater agreement was measured using Cohen's κ. Extracted data were analyzed using descriptive statistics. RESULTS A total of 37 articles met the study inclusion criteria. Cohen's κ for study inclusion/exclusion and data abstraction was 0.88 and 0.97, respectively. Most studies validated administrative data from the USA (43.2%) and Canada (24.3%), and focused on inpatient records (67.6%). Case-finding algorithms (56.7%) were more frequently validated than diagnoses codes alone (37.8%). Five conditions were validated in more than one study: diabetes mellitus, inflammatory bowel disease, asthma, rotavirus infection, and tuberculosis. CONCLUSIONS This scoping review identified a number of gaps in the validation of administrative health data for pediatric populations, including limited investigation of outpatient populations and older pediatric age groups.
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Affiliation(s)
- Natalie J Shiff
- Department of Pediatrics, College of Medicine, University of Saskatchewan, 103 Hospital Drive, SK S7N 0W8, Saskatoon, Canada
| | - Sadia Jama
- Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, 103 Hospital Drive, SK S7N 0W8, Saskatoon, Canada
| | - Catherine Boden
- University Library, University of Saskatchewan, Room 1441, Leslie and Irene Dube Health Sciences Library, 104 Clinic Place, SK S7N 5E5, Saskatoon, Canada
| | - Lisa M Lix
- Department of Community Health Sciences, S113-750 Bannatyne Avenue, University of Manitoba, MB R3E 0W3, Winnipeg, Canada
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Data-driven discovery of seasonally linked diseases from an Electronic Health Records system. BMC Bioinformatics 2014; 15 Suppl 6:S3. [PMID: 25078762 PMCID: PMC4158606 DOI: 10.1186/1471-2105-15-s6-s3] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Patterns of disease incidence can identify new risk factors for the disease or provide insight into the etiology. For example, allergies and infectious diseases have been shown to follow periodic temporal patterns due to seasonal changes in environmental or infectious agents. Previous work searching for seasonal or other temporal patterns in disease diagnosis rates has been limited both in the scope of the diseases examined and in the ability to distinguish unexpected seasonal patterns. Electronic Health Records (EHR) compile extensive longitudinal clinical information, constituting a unique source for discovery of trends in occurrence of disease. However, the data suffer from inherent biases that preclude an identification of temporal trends. METHODS Motivated by observation of the biases in this data source, we developed a method (Lomb-Scargle periodograms in detrended data, LSP-detrend) to find periodic patterns by adjusting the temporal information for broad trends in incidence, as well as seasonal changes in total hospitalizations. LSP-detrend can sensitively uncover periodic temporal patterns in the corrected data and identify the significance of the trend. We apply LSP-detrend to a compilation of records from 1.5 million patients encoded by ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification), including 2,805 disorders with more than 500 occurrences across a 12 year period, recorded from 1.5 million patients. RESULTS AND CONCLUSIONS Although EHR data, and ICD-9 coded records in particular, were not created with the intention of aggregated use for research, these data can in fact be mined for periodic patterns in incidence of disease, if confounders are properly removed. Of all diagnoses, around 10% are identified as seasonal by LSP-detrend, including many known phenomena. We robustly reproduce previous findings, even for relatively rare diseases. For instance, Kawasaki disease, a rare childhood disease that has been associated with weather patterns, is detected as strongly linked with winter months. Among the novel results, we find a bi-annual increase in exacerbations of myasthenia gravis, a potentially life threatening complication of an autoimmune disease. We dissect the causes of this seasonal incidence and propose that factors predisposing patients to this event vary through the year.
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Berlan ED, Ireland AM, Morton S, Byron SC, Canan BD, Kelleher KJ. Variations in measurement of sexual activity based on EHR definitions. Pediatrics 2014; 133:e1305-12. [PMID: 24733876 DOI: 10.1542/peds.2013-3232] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal of this study was to compare the performance of 4 operational definitions of sexual activity by using data electronically abstracted from electronic health records (EHRs) and examine how documentation of Chlamydia screening and positivity vary according to definition of sexual activity. METHODS Extracts were created from EHRs of adolescent females 12 to 19 years old who had ≥1 visit to a primary care practice during 2011 at 4 US pediatric health care organizations. We created 4 definitions of sexual activity derived from electronically abstracted indicator variables. Percent sexually active, documentation of Chlamydia screening, and rate of positive Chlamydia test results per 1000 adolescent females according to the sexual activity definition were calculated. RESULTS The most commonly documented individual indicator of sexual activity was "patient report of being sexually active" (mean across 4 sites: 19.2%). The percentage of adolescent females classified as sexually active varied by site and increased as more indicator variables were included. As the definition of sexual activity expanded, the percentage of sexually active females who received at least 1 Chlamydia test decreased. Using a broader definition of sexual activity resulted in improved identification of adolescent females with Chlamydia infection. For each sexual activity definition and performance item, the difference was statistically significant (P < .0001). CONCLUSIONS Information about sexual activity may be gathered from a variety of data sources, and changing the configurations of these indicators results in differences in the percentage of adolescent females classified as sexually active, screened for Chlamydia infection, and Chlamydia infection rates.
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Affiliation(s)
- Elise D Berlan
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Section of Adolescent Medicine, Nationwide Children's Hospital, Columbus, Ohio; Centers for Clinical and Translational Research, and
| | - Andrea M Ireland
- National Committee for Quality Assurance, Washington, District of Columbia
| | - Suzanne Morton
- National Committee for Quality Assurance, Washington, District of Columbia
| | - Sepheen C Byron
- National Committee for Quality Assurance, Washington, District of Columbia
| | - Benjamin D Canan
- Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; and
| | - Kelly J Kelleher
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio; Innovation in Pediatric Practice, The Research Institute at Nationwide Children's Hospital, Columbus, Ohio; and
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Schaffzin JK, Dodd CN, Nguyen H, Schondelmeyer A, Campanella S, Goldstein SL. Administrative data misclassifies and fails to identify nephrotoxin-associated acute kidney injury in hospitalized children. Hosp Pediatr 2014; 4:159-166. [PMID: 24785560 DOI: 10.1542/hpeds.2013-0116] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES Nephrotoxin exposure is a common cause of acute kidney injury (AKI) in hospitalized children. AKI detection relies on regular serum creatinine (SCr) screening among exposed patients. We sought to determine how well administrative data identify hospitalized noncritically ill children with nephrotoxic medication-associated AKI in the contexts of incomplete and complete screening. METHODS We conducted a single-center retrospective cohort study among noncritically ill hospitalized children. We compared administrative data sensitivity to that among a separate cohort for whom adequate screening was defined as daily SCr measurement. For the original cohort, nephrotoxin exposure was defined as exposure to ≥3 nephrotoxins at once or ≥3 days of aminoglycoside therapy. AKI was defined by the change in SCr (pediatric-modified Risk Injury Failure Loss End-Stage Renal Disease [pRIFLE] criteria) or discharge code. Adequate SCr screening was defined as 2 measurements obtained ≤96 hours apart. Administrative data and laboratory values were merged to compare AKI by discharge code and pRIFLE criteria. RESULTS 747 of 1472 (50.7%) nephrotoxin-exposed patients were adequately screened; 82 (11.0%) had AKI by pRIFLE criteria, 52 (7.0%) by discharge code. Sensitivity of nephrotoxin-associated AKI diagnosis by discharge code compared with pRIFLE criteria was 23.2% (95% confidence interval = 14.0-32.3). In the comparison cohort, 70 (26.8%) patients had AKI by pRIFLE criteria and 26 (10.0%) by discharge code; sensitivity was 21.4% (95% confidence interval = 11.8%-31.0%). CONCLUSIONS pRIFLE criteria identified more patients than were identified by discharge code. Identifying patients with nephrotoxin-associated AKI by discharge code, even in the presence of complete AKI detection, underrepresents the true incidence of nephrotoxin-associated AKI in hospitalized children.
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Jain S, Cheng J, Alpern ER, Thurm C, Schroeder L, Black K, Ellison AM, Stone K, Alessandrini EA. Management of febrile neonates in US pediatric emergency departments. Pediatrics 2014; 133:187-95. [PMID: 24470644 DOI: 10.1542/peds.2013-1820] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P < .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management. CONCLUSIONS There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.
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Affiliation(s)
- Shabnam Jain
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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Abhyankar S, Demner-Fushman D, Callaghan FM, McDonald CJ. Combining structured and unstructured data to identify a cohort of ICU patients who received dialysis. J Am Med Inform Assoc 2014; 21:801-7. [PMID: 24384230 DOI: 10.1136/amiajnl-2013-001915] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE To develop a generalizable method for identifying patient cohorts from electronic health record (EHR) data-in this case, patients having dialysis-that uses simple information retrieval (IR) tools. METHODS We used the coded data and clinical notes from the 24,506 adult patients in the Multiparameter Intelligent Monitoring in Intensive Care database to identify patients who had dialysis. We used SQL queries to search the procedure, diagnosis, and coded nursing observations tables based on ICD-9 and local codes. We used a domain-specific search engine to find clinical notes containing terms related to dialysis. We manually validated the available records for a 10% random sample of patients who potentially had dialysis and a random sample of 200 patients who were not identified as having dialysis based on any of the sources. RESULTS We identified 1844 patients that potentially had dialysis: 1481 from the three coded sources and 1624 from the clinical notes. Precision for identifying dialysis patients based on available data was estimated to be 78.4% (95% CI 71.9% to 84.2%) and recall was 100% (95% CI 86% to 100%). CONCLUSIONS Combining structured EHR data with information from clinical notes using simple queries increases the utility of both types of data for cohort identification. Patients identified by more than one source are more likely to meet the inclusion criteria; however, including patients found in any of the sources increases recall. This method is attractive because it is available to researchers with access to EHR data and off-the-shelf IR tools.
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Affiliation(s)
- Swapna Abhyankar
- National Library of Medicine, National Institutes of Health, Lister Hill National Center for Biomedical Communications, Bethesda, Maryland, USA
| | - Dina Demner-Fushman
- National Library of Medicine, National Institutes of Health, Lister Hill National Center for Biomedical Communications, Bethesda, Maryland, USA
| | - Fiona M Callaghan
- National Library of Medicine, National Institutes of Health, Lister Hill National Center for Biomedical Communications, Bethesda, Maryland, USA
| | - Clement J McDonald
- National Library of Medicine, National Institutes of Health, Lister Hill National Center for Biomedical Communications, Bethesda, Maryland, USA
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O'Callaghan J, Quinonez R. Moving beyond administrative data sets and coding data. Hosp Pediatr 2013; 3:314-316. [PMID: 24435187 DOI: 10.1542/hpeds.2013-0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- James O'Callaghan
- Seattle Children's Hospital/University of Washington, Seattle, Washington; and
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Williams DJ, Shah SS, Myers A, Hall M, Auger K, Queen MA, Jerardi K, McClain L, Wiggleton C, Tieder JS. Identifying pediatric community-acquired pneumonia hospitalizations: Accuracy of administrative billing codes. JAMA Pediatr 2013; 167:851-8. [PMID: 23896966 PMCID: PMC3907952 DOI: 10.1001/jamapediatrics.2013.186] [Citation(s) in RCA: 105] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Community-acquired pneumonia (CAP) remains one of the most common indications for pediatric hospitalization in the United States, and it is frequently the focus of research and quality studies. Use of administrative data is increasingly common for these purposes, although proper validation is required to ensure valid study conclusions. OBJECTIVE To validate administrative billing data for hospitalizations owing to childhood CAP. DESIGN AND SETTING Case-control study of 4 tertiary care, freestanding children’s hospitals in the United States. PARTICIPANTS A total of 998 medical records of a 25% random sample of 3646 children discharged in 2010 with at least 1 International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code representing possible pneumonia were reviewed. Discharges (matched on date of admission) without a pneumonia-related discharge code were also examined to identify potential missed pneumonia cases. Two reference standards, based on provider diagnosis alone (provider confirmed) or in combination with consistent clinical and radiographic evidence of pneumonia (definite), were used to identify CAP. EXPOSURE Twelve ICD-9-CM–based coding strategies, each using a combination of primary or secondary codes representing pneumonia or pneumonia-related complications. Six algorithms excluded children with complex chronic conditions. MAIN OUTCOMES AND MEASURES Sensitivity, specificity, and negative and positive predictive values (NPV and PPV, respectively) of the 12 identification strategies. RESULTS For provider-confirmed CAP (n = 680), sensitivity ranged from 60.7% to 99.7%; specificity, 75.7% to 96.4%; PPV, 67.9% to 89.6%; and NPV, 82.6% to 99.8%. For definite CAP (n = 547), sensitivity ranged from 65.6% to 99.6%; specificity, 68.7% to 93.0%; PPV, 54.6% to 77.9%; and NPV, 87.8% to 99.8%. Unrestricted use of the pneumonia-related codes was inaccurate, although several strategies improved specificity to more than 90% with a variable effect on sensitivity. Excluding children with complex chronic conditions demonstrated the most favorable performance characteristics. Performance of the algorithms was similar across institutions. CONCLUSIONS AND RELEVANCE Administrative data are valuable for studying pediatric CAP hospitalizations. The strategies presented here will aid in the accurate identification of relevant and comparable patient populations for research and performance improvement studies.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Samir S. Shah
- Divisions of Infectious Diseases and Hospital Medicine, Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Angela Myers
- Division of Infectious Diseases, Children’s Mercy Hospital and Clinics and the University of Missouri School of Medicine, Kansas City, MO
| | - Matthew Hall
- The Children’s Hospital Association, Overland Park, KS
| | - Katherine Auger
- Robert Wood Johnson Foundation Clinical Scholars Fellow and the Division of General Pediatrics, University of Michigan, Ann Arbor, MI
| | - Mary Ann Queen
- Section of Hospital Medicine, Children’s Mercy Hospital and Clinics and the University of Missouri School of Medicine, Kansas City, MO
| | - Karen Jerardi
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and the Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lauren McClain
- The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Catherine Wiggleton
- Division of Hospital Medicine, The Monroe Carell, Jr. Children’s Hospital at Vanderbilt and the Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Joel S. Tieder
- Division of Hospital Medicine, Seattle Children’s Hospital and the Department of Pediatrics, University of Washington School of Medicine, Seattle, WA
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Mannix R, Monuteaux MC, Schutzman SA, Meehan WP, Nigrovic LE, Neuman MI. Isolated skull fractures: trends in management in US pediatric emergency departments. Ann Emerg Med 2013; 62:327-31. [PMID: 23602429 DOI: 10.1016/j.annemergmed.2013.02.027] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2012] [Revised: 02/18/2013] [Accepted: 02/28/2013] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE Previous studies have suggested that children with isolated skull fractures are at low risk of requiring neurosurgical intervention, suggesting that admission to the hospital may not be necessary in many instances. We seek to evaluate current practice for children presenting to the emergency department (ED) for isolated skull fractures in US children's hospitals. METHODS We conducted a retrospective multicenter cross-sectional study of children younger 19 years with a diagnosis of isolated skull fracture who were evaluated in the ED from 2005 to 2011, using the Pediatric Health Information System database. The primary outcome measure was the rate of hospital admission. Secondary outcomes were any neurosurgical procedure during hospitalization, repeated neuroimaging, duration of hospitalization, and cost of care. RESULTS We identified 3,915 patients with isolated skull fractures, of whom 60% were male patients; 78% were hospitalized. Of hospitalized children, 85% were discharged within 1 day and 95% were discharged within 2 days. During hospitalization, 47 patients received repeated computed tomography imaging and 1 child required a neurosurgical procedure. Hospital costs were more than triple for hospitalized patients compared with patients discharged from the ED ($2,064 versus $619). CONCLUSION Most children treated in EDs of US children's hospitals with isolated skull fractures are hospitalized. The rate of neurosurgical intervention is very low. A better understanding of current practice is necessary to assess whether these admissions are warranted or not.
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Affiliation(s)
- Rebekah Mannix
- Division of Emergency Medicine, Department of Medicine, Boston Children's Hospital, and Harvard Medical School, Harvard University, Boston, MA.
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Levine PJ, Elman MR, Kullar R, Townes JM, Bearden DT, Vilches-Tran R, McClellan I, McGregor JC. Use of electronic health record data to identify skin and soft tissue infections in primary care settings: a validation study. BMC Infect Dis 2013; 13:171. [PMID: 23574801 PMCID: PMC3637223 DOI: 10.1186/1471-2334-13-171] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Accepted: 04/04/2013] [Indexed: 11/14/2022] Open
Abstract
Background Epidemiologic studies of skin and soft tissue infections (SSTIs) depend upon accurate case identification. Our objective was to evaluate the positive predictive value (PPV) of electronic medical record data for identification of SSTIs in a primary care setting. Methods A validation study was conducted among primary care outpatients in an academic healthcare system. Encounters during four non-consecutive months in 2010 were included if any of the following were present in the electronic health record: International Classification of Diseases, Ninth Revision (ICD-9) code for an SSTI, Current Procedural Terminology (CPT) code for incision and drainage, or a positive wound culture. Detailed chart review was performed to establish presence and type of SSTI. PPVs and 95% confidence intervals (CI) were calculated among all encounters, initial encounters, and cellulitis/abscess cases. Results Of the 731 encounters included, 514 (70.3%) were initial encounters and 448 (61.3%) were cellulitis/abscess cases. When the presence of an ICD-9 code, CPT code, or positive culture was used to identify SSTIs, 617 encounters were true positives, yielding a PPV of 84.4% [95% CI: 81.8–87.0%]. The PPV for using ICD-9 codes alone to identify SSTIs was 90.7% [95 % CI: 88.5–92.9%]. For encounters with cellulitis/abscess codes, the PPV was 91.5% [95% CI: 88.9–94.1%]. Conclusions ICD-9 codes may be used to retrospectively identify SSTIs with a high PPV. Broadening SSTI case identification with microbiology data and CPT codes attenuates the PPV. Further work is needed to estimate the sensitivity of this method.
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Affiliation(s)
- Pamela J Levine
- Department of Pharmacy Practice, College of Pharmacy, Oregon State University/Oregon Health & Science University, 3303 SW Bond Avenue CH12C, Portland, OR 97239, USA
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Affiliation(s)
- Lilliam V Ambroggio
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH 45229, USA
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Parker MW, Schaffzin JK, Lo Vecchio A, Yau C, Vonderhaar K, Guiot A, Brinkman WB, White CM, Simmons JM, Gerhardt WE, Kotagal UR, Conway PH. Rapid adoption of Lactobacillus rhamnosus GG for acute gastroenteritis. Pediatrics 2013; 131 Suppl 1:S96-102. [PMID: 23457156 PMCID: PMC4258826 DOI: 10.1542/peds.2012-1427l] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2012] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES A 2007 meta-analysis showed probiotics, specifically Lactobacillus rhamnosus GG (LGG), shorten diarrhea from acute gastroenteritis (AGE) by 24 hours and decrease risk of progression beyond 7 days. In 2005, our institution published a guideline recommending consideration of probiotics for patients with AGE, but only 1% of inpatients with AGE were prescribed LGG. The objective of this study was to increase inpatient prescribing of LGG at admission to >90%, for children hospitalized with AGE, within 120 days. METHODS This quality improvement study included patients aged 2 months to 18 years admitted to general pediatrics with AGE with diarrhea. Diarrhea was defined as looser or ≥ 3 stools in the preceding 24 hours. Patients with complex medical conditions or with presumed bacterial gastroenteritis were excluded. Admitting and supervising clinicians were educated on the evidence. We ensured LGG was adequately stocked in our pharmacies and updated an AGE-specific computerized order set to include a default LGG order. Failure identification and mitigation were conducted via daily electronic chart review and e-mail communication. Primary outcome was the percentage of included patients prescribed LGG within 18 hours of admission. Intervention impact was assessed with run charts tracking our primary outcome over time. RESULTS The prescribing rate increased to 100% within 6 weeks and has been sustained for 7 months. CONCLUSIONS Keys to success were pharmacy collaboration, use of an electronic medical record for a standardized order set, and rapid identification and mitigation of failures. Rapid implementation of evidence-based practices is possible using improvement science methods.
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Affiliation(s)
- Michelle W Parker
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 3024, Cincinnati, OH 45229-3039, USA.
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Jerardi KE, Auger KA, Shah SS, Hall M, Hain PD, Myers AL, Williams DJ, Tieder JS. Discordant antibiotic therapy and length of stay in children hospitalized for urinary tract infection. J Hosp Med 2012; 7:622-7. [PMID: 22833498 DOI: 10.1002/jhm.1960] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Revised: 05/31/2012] [Accepted: 06/15/2012] [Indexed: 11/06/2022]
Abstract
BACKGROUND Urinary tract infections (UTIs) are a common reason for pediatric hospitalizations. OBJECTIVE To determine the effect of discordant antibiotic therapy (in vitro nonsusceptibility of the uropathogen to initial antibiotic) on clinical outcomes for children hospitalized for UTI. DESIGN/SETTING Multicenter retrospective cohort study in children aged 3 days to 18 years, hospitalized at 5 children's hospitals with a laboratory-confirmed UTI. Data were obtained from medical records and the Pediatric Hospital Information System (PHIS) database. PARTICIPANTS Patients with laboratory-confirmed UTI. MAIN EXPOSURE Discordant antibiotic therapy. MEASUREMENTS Length of stay and fever duration. Covariates included age, sex, insurance, race, vesicoureteral reflux, antibiotic prophylaxis, genitourinary abnormality, and chronic care conditions. RESULTS The median age of the 216 patients was 2.46 years (interquartile range [IQR]: 0.27, 8.89) and 25% were male. The most common causative organisms were E. coli and Klebsiella species. Discordant therapy occurred in 10% of cases and most commonly in cultures positive for Klebsiella species, Enterobacter species, and mixed organisms. In adjusted analyses, discordant therapy was associated with a 1.8 day (95% confidence interval [CI]: 1.5, 2.1) longer length of stay [LOS], but not with fever duration. CONCLUSIONS Discordant antibiotic therapy for UTI is common and associated with longer hospitalizations. Further research is needed to understand the clinical factors contributing to the increased LOS and to inform decisions for empiric antibiotic selection in children with UTIs.
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Affiliation(s)
- Karen E Jerardi
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio 45229-3039, USA.
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