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Schondelmeyer AC, Sauers-Ford H, Touzinsky SM, Brady PW, Britto MT, Molloy MJ, Simmons JM, Cvach MM, Shah SS, Vaughn LM, Won J, Walsh KE. Clinician Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study. Hosp Pediatr 2024; 14:649-657. [PMID: 39044720 PMCID: PMC11287064 DOI: 10.1542/hpeds.2023-007638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 04/03/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND AND OBJECTIVES Variation in continuous cardiopulmonary monitor (cCPM) use across children's hospitals suggests preference-based use. We sought to understand how clinical providers make decisions to use cCPMs. METHODS We conducted a qualitative study using semi-structed interviews with clinicians (nurses, respiratory therapists [RTs], and resident and attending physicians) from 2 hospital medicine units at a children's hospital. The interview guide employed patient cases and open-ended prompts to elicit information about workflows and decision-making related to cCPM, and we collected basic demographic information about participants. We used an inductive approach following thematic analysis to code transcripts and create themes. RESULTS We interviewed 5 nurses, 5 RTs, 7 residents, and 7 attending physicians. We discovered that clinicians perceive a low threshold for starting cCPM, and this often occurred as a default action at admission. Clinicians thought of cCPMs as helping them cope with uncertainty. Despite acknowledging considerable flaws in how cCPMs were used, they were perceived as a low-risk intervention. Although RNs and RTs were most aware of the patient's current condition and number of alarms, physicians decided when to discontinue monitors. No structured process for identifying when to discontinue monitors existed. CONCLUSIONS We concluded that nurses, physicians, and RTs often default to cCPM use and lack a standardized process for identifying when cCPM should be discontinued. Interventions aiming to reduce monitor use will need to account for or target these factors.
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Affiliation(s)
- Amanda C. Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
| | | | - Sara M. Touzinsky
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus Ohio
| | - Patrick W. Brady
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence
| | - Maria T. Britto
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence
| | - Matthew J. Molloy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- Division of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | | | | | - Samir S. Shah
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
| | - Lisa M. Vaughn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Emergency Medicine, Department of Pediatrics, Nationwide Children’s Hospital, Columbus Ohio
- Educational and Community-Based Action Research PhD Program, University of Cincinnati College of Education, Criminal Justice & Human Services, Cincinnati, Ohio
| | - James Won
- Human Factors and System Design, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- School of Medicine
- School of Engineering, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Kathleen E. Walsh
- Division of General Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Gill PJ, Buchanan F, Fahim C, Borkhoff CM, Raza S, Buba M, Wahi G, Bayliss A, Zhou K, Kanani R, Sakran M, De Castris-Garcia K, Barrowman N, Klassen T, Schuh S, Hulst J, Straus S, Macarthur C, Sozer A, Elwyn G, Breen-Reid K, Mahant S. Parenteral versus enteral fluids for infants hospitalized with bronchiolitis: The PREFER shared decision-making prospective observational study protocol. J Hosp Med 2024. [PMID: 38923338 DOI: 10.1002/jhm.13426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2024] [Revised: 05/16/2024] [Accepted: 05/19/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Incorporating shared decision-making (SDM) with children and families in hospitals was a top priority identified by patients, caregivers, and clinicians. Bronchiolitis, a common and costly reason for hospitalization in children, is an exemplar condition to study SDM in hospitals. Internationally, clinical practice guidelines differ when recommending intravenous (IV or parenteral) or nasogastric (NG or enteral) fluids for hospitalized infants with bronchiolitis who are unsafe to be fed orally. While evidence indicates that either IV or NG fluids are safe and effective, parent involvement in SDM in selecting IV or NG fluids is unknown. Our aim is to generate knowledge of SDM with parents in choosing between IV or NG fluids and the benefits and harms of these two treatment options for hospitalized children with bronchiolitis. METHOD This is a multicenter, prospective, observational study, including children aged <12 months admitted to hospital with bronchiolitis requiring supplemental IV or NG fluids. The primary outcome will evaluate the extent of SDM in choosing IV versus NG fluids using the validated CollaboRATE tool. Secondary outcomes include the proportion of parents provided a choice of IV versus NG fluids; parent knowledge of fluid therapy; rate of fluids; length of hospital stay; and complications. DISCUSSION This study will evaluate the extent of SDM in hospitalized infants with bronchiolitis who require IV or NG fluids and will evaluate both patient-centered and clinical outcomes that are relevant to clinical practice.
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Affiliation(s)
- Peter J Gill
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Francine Buchanan
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Christine Fahim
- Implementation, Evaluation and Sustainability, Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
| | - Cornelia M Borkhoff
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Shamama Raza
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Melanie Buba
- Division of Pediatric Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
- McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Department of Paediatrics, Trillium Health Partners Credit Valley Hospital, Mississauga, Ontario, Canada
| | - Kim Zhou
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
- Department of Pediatrics, Queen's University, Kingston, Ontario, Canada
| | - Kim De Castris-Garcia
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Terry Klassen
- Children's Hospital Research Institute of Manitoba, Winnipeg, Manitoba, Canada
- Department of Pediatrics & Child Health, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Suzanne Schuh
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Jessie Hulst
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada
| | - Sharon Straus
- Implementation, Evaluation and Sustainability, Knowledge Translation Program, St Michael's Hospital Li Ka Shing Knowledge Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Geriatrics, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Colin Macarthur
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
| | - Aubrey Sozer
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire, USA
| | - Karen Breen-Reid
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Division of Pediatric Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, The University of Toronto, Toronto, Ontario, Canada
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Lee V, Ruppel H, Schondelmeyer AC. Pulse Oximetry in Bronchiolitis: Have We Reached Saturation? Hosp Pediatr 2024; 14:e107-e109. [PMID: 38164077 DOI: 10.1542/hpeds.2023-007505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Affiliation(s)
- Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California
- Department of Pediatrics, Keck School of Medicine of University of Southern California, Los Angeles, California
| | - Halley Ruppel
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania
- Clinical Futures, The Children's Hospital of Philadelphia Research Institute, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- Division of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Im JHB, Wahi G, Giglia L, Bayliss A, Kanani R, Pound CM, Sakran M, Schuh S, Gill PJ, Parkin PC, Barrowman N, Mahant S. Oxygen Saturation Targets in Infants Hospitalized With Bronchiolitis: A Multicenter Cohort Study. Hosp Pediatr 2024; 14:67-74. [PMID: 38164101 DOI: 10.1542/hpeds.2023-007301] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
OBJECTIVES To examine 2 hospital oxygen saturation target policies and clinical outcomes in infants hospitalized with bronchiolitis. METHODS This multicenter cohort study used data collected from a randomized clinical trial of infants aged 4 weeks to 24 months, hospitalized with bronchiolitis at children's and community hospitals from 2016 to 2019. We modeled the association between hospital oxygen saturation target policy, either 90% while awake and 88% while asleep (90%/88%) or 90% while awake and asleep (90%/90%), and clinical outcomes. RESULTS A total of 162 infants were enrolled at 4 hospitals using a 90%/88% oxygen saturation target and 67 infants at 2 hospitals using a 90%/90% target policy. No significant differences between the 90%/88% group and 90%/90% groups were observed for time to discharge (adjusted hazard ratio, 0.83; 95% confidence interval [CI], 0.61-1.14; P = .25), initiation of supplemental oxygen (adjusted odds ratio [aOR], 0.98; 95% CI, 0.47-2.02; P = .95), time to discontinuation of supplemental oxygen (adjusted hazard ratio, 0.75; 95% CI, 0.44-1.27; P = .28), revisits (aOR, 1.38; 95% CI, 0.52-3.71; P = .52), and parent days missed from work (aOR, 2.41; 95% CI, 0.90-6.41; P = .08). Three infants in the 90%/88% group and none in the 90%/90% group were transferred to the ICU. CONCLUSIONS Among infants hospitalized with bronchiolitis, clinical outcomes were similar between a hospital oxygen saturation target policy of 90% while awake and 88% while asleep compared with 90% while awake and asleep. These findings may inform the design of future trials of oxygen saturation targets in bronchiolitis hospital care.
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Affiliation(s)
- James H B Im
- Dalla Lana School of Public Health
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Lucy Giglia
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston, Ontario, Canada
| | - Suzanne Schuh
- Department of Pediatrics
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Peter J Gill
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Patricia C Parkin
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Nicholas Barrowman
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
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5
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Yama B, Wahi G, Zhou K, Bayliss A, Sakran M, Breen-Reid K, Pound C, Beck C, Friedman J, Arafeh D, Kanani R, Parkin P, Mahant S. De-implementing low-value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study. J Hosp Med 2023; 18:1092-1101. [PMID: 37932871 DOI: 10.1002/jhm.13236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Clinical trial evidence supports the routine use of intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. However, continuous pulse oximetry use is common. OBJECTIVE This study aimed to understand the barriers and facilitators to de-implement continuous pulse oximetry and implement intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis. METHODS This multicentre qualitative study interviewed attending pediatricians, residents, nurses, respiratory therapists, and caregivers of infants hospitalized with bronchiolitis at hospitals in Ontario, Canada, to explore beliefs, attitudes, and experiences regarding pulse oximetry use in bronchiolitis management. Data were analyzed using thematic analysis to understand barriers and facilitators to practice change, mapped to the Consolidated Framework for Implementation Research (CFIR) domains. RESULTS Sixty-seven participants from six hospitals were interviewed using individual interviews and focus groups. Healthcare providers emphasized the importance of identifying and understanding who is responsible for bedside pulse oximetry practice (physicians vs. nurses). Clinical experience, knowledge of guidelines, importance versus competing priorities, and the tensions among team members due to practice variation in monitoring, influenced monitoring practice. Nurses believed in the advantages of intermittent monitoring (reduced alarm fatigue, facilitation of timely discharges, and reduced workload). Clinicians identified ways to clarify indications for continuous monitoring (based on patient risk factors), versus indications to transition to intermittent monitoring (established oral feeding, sleeping without desaturations). Caregivers did not express a clear preference for monitoring type; rather, they described the need for clear communication around interpreting monitor readings, management decisions, and care transitions. CONCLUSIONS Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry practice is essential for practice change. These findings may inform hospital quality improvement efforts to de-implement continuous monitoring in bronchiolitis hospital care.
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Affiliation(s)
- Brie Yama
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Gita Wahi
- Department of Pediatrics, Division of General Pediatrics, McMaster University and McMaster Children's Hospital, Hamilton, Ontario, Canada
| | - Kim Zhou
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Ann Bayliss
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Children's Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queen's University, Kingston, Ontario, Canada
| | - Karen Breen-Reid
- Lawrence Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Catherine Pound
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Carolyn Beck
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jeremy Friedman
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
| | - Dana Arafeh
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Patricia Parkin
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Sanjay Mahant
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
- Hospital for Sick Children, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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6
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Lawrence J, Hiscock H, South M. Bronchiolitis - The Simple Things in Life…. Hosp Pediatr 2023; 13:e314-e318. [PMID: 37706241 DOI: 10.1542/hpeds.2023-007237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Affiliation(s)
- Joanna Lawrence
- Electronic Medical Record Team, Royal Children's Hospital, Melbourne, Australia
- Health Services Research Unit, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- School of Population Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Harriet Hiscock
- Health Services Research Unit, Murdoch Children's Research Institute, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
| | - Mike South
- Electronic Medical Record Team, Royal Children's Hospital, Melbourne, Australia
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
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Faerber JA, Xiao R, Makeneni S, Schisterman EF, Brady PW, Schondelmeyer AC, Landrigan CP, Lucey K, Lee V, Gregory PF, Prasto J, Parthasarathy P, Greenfield M, Solomon C, Brent CR, Albanowski K, Beidas RS, Bonafide CP. Sustainment of continuous pulse oximetry deimplementation: Analysis of Eliminating Monitor Overuse study data from six hospitals. J Hosp Med 2023; 18:724-729. [PMID: 37380625 PMCID: PMC10527429 DOI: 10.1002/jhm.13154] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/30/2023]
Abstract
Using continuous pulse oximetry (cSpO2 ) to monitor children with bronchiolitis who are not receiving supplemental oxygen is a form of medical overuse. In this longitudinal analysis from the Eliminating Monitor Overuse (EMO) study, we aimed to assess changes in cSpO2 overuse before, during, and after intensive cSpO2 -deimplementation efforts in six hospitals. Monitoring data were collected during three phases: "P1" baseline, "P2" active deimplementation (all sites engaged in education and audit and feedback strategies), and "P3" sustainment (a new baseline measured after strategies were withdrawn). Two thousand and fifty-three observations were analyzed. We found that each hospital experienced reductions during active deimplementation (P2), with overall adjusted cSpO2 overuse decreasing from 53%, 95% confidence interval (CI): (49-57) to 22%, 95% CI: (19-25) between P1 and P2. However, following the withdrawal of deimplementation strategies, overuse rebounded in all six sites, with overall adjusted cSpO2 overuse increasing to 37%, 95% CI: (33-41) in P3.
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Affiliation(s)
- Jennifer A Faerber
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Spandana Makeneni
- Data Science and Biostatistics Unit, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio, USA
| | - Christopher P Landrigan
- Division of General Pediatrics, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Departments of Pediatrics and Medicine, and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Kate Lucey
- Division of Hospital Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Vivian Lee
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
- Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Polina F Gregory
- Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
- Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Julianne Prasto
- Division of Pediatrics, Children's Hospital of Philadelphia Pediatric Care at Penn Medicine Princeton Medical Center, Plainsboro, New Jersey, USA
| | - Padmavathy Parthasarathy
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Morgan Greenfield
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Courtney Solomon
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
- Division of Pediatric Hospital Medicine, Children's Health Dallas, Dallas, Texas, USA
| | - Canita R Brent
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rinad S Beidas
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Evanston, Illinois, USA
| | - Christopher P Bonafide
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Clinical Futures, a Center of Emphasis within the CHOP Research Institute, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, Pennsylvania, USA
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8
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Briggs S, Gupta V, Thakkar N, Librizzi J, Temkit H, Engel R. Decreasing Goal Oxygen Saturations in Bronchiolitis Is Associated With Decreased Length of Stay. Hosp Pediatr 2023:e2022007020. [PMID: 37449328 DOI: 10.1542/hpeds.2022-007020] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
OBJECTIVES For patients hospitalized with bronchiolitis, many hospitals have implemented clinical practice guidelines to decrease variability in care. Our hospital updated its bronchiolitis clinical pathway by lowering goal oxygen saturation from 90% to 88%. We compared clinical outcomes before and after this change within the context of the pathway update. METHODS This was a retrospective analysis of patients <24 months old admitted to a pediatric tertiary care center from 2019 to 2021 with bronchiolitis. Patients with congenital heart disease, asthma, home oxygen, or admitted to an ICU were excluded. The data were stratified for patients admitted before and after the clinical pathway update. Statistical methods consisted of 2 group comparisons using the χ-square test for categorical variables, the Wilcoxon rank-sum test for continuous variables, and multiple regression analysis. RESULTS A total of 1386 patients were included, 779 preupdate and 607 postupdate. There was no statistically significant difference in the admission rate of patients presenting to the emergency department with bronchiolitis between the 2 groups (P value .60). The median time to room air was 40.0 hours preupdate versus 30.0 hours postupdate (P value < .001). The median length of stay was 48.0 hours preupdate versus 41.0 hours postupdate (P value < .001). Readmission rate was 2.7% within 7 days of discharge preupdate, and 2.1% postupdate (P value .51). CONCLUSIONS Decreasing goal oxygen saturation to 88% was associated with a statistically significant decrease in time spent on oxygen and length of stay for patients admitted with bronchiolitis with no increase in readmissions.
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Affiliation(s)
- Shivani Briggs
- The University of Texas at Houston Health Science Center, Houston, Texas; and
| | | | | | | | - Hamy Temkit
- Phoenix Children's Hospital, Phoenix, Arizona
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Walker SB, Badke CM, Carroll MS, Honegger KS, Fawcett A, Weese-Mayer DE, Sanchez-Pinto LN. Novel approaches to capturing and using continuous cardiorespiratory physiological data in hospitalized children. Pediatr Res 2023; 93:396-404. [PMID: 36329224 DOI: 10.1038/s41390-022-02359-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 08/16/2022] [Accepted: 10/11/2022] [Indexed: 11/06/2022]
Abstract
Continuous cardiorespiratory physiological monitoring is a cornerstone of care in hospitalized children. The data generated by monitoring devices coupled with machine learning could transform the way we provide care. This scoping review summarizes existing evidence on novel approaches to continuous cardiorespiratory monitoring in hospitalized children. We aimed to identify opportunities for the development of monitoring technology and the use of machine learning to analyze continuous physiological data to improve the outcomes of hospitalized children. We included original research articles published on or after January 1, 2001, involving novel approaches to collect and use continuous cardiorespiratory physiological data in hospitalized children. OVID Medline, PubMed, and Embase databases were searched. We screened 2909 articles and performed full-text extraction of 105 articles. We identified 58 articles describing novel devices or approaches, which were generally small and single-center. In addition, we identified 47 articles that described the use of continuous physiological data in prediction models, but only 7 integrated multidimensional data (e.g., demographics, laboratory results). We identified three areas for development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using continuous cardiorespiratory data. IMPACT: We performed a comprehensive scoping review of novel approaches to capture and use continuous cardiorespiratory physiological data for monitoring, diagnosis, providing care, and predicting events in hospitalized infants and children, from novel devices to machine learning-based prediction models. We identified three key areas for future development: (1) further validation of promising novel devices; (2) more studies of models integrating multidimensional data with continuous cardiorespiratory data; and (3) further dissemination, implementation, and validation of prediction models using cardiorespiratory data.
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Affiliation(s)
- Sarah B Walker
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Colleen M Badke
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Michael S Carroll
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Kyle S Honegger
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Andrea Fawcett
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Debra E Weese-Mayer
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - L Nelson Sanchez-Pinto
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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10
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Wertheim D, Anton O, Olden C, Le Maistre SLV, Seddon PC. Pulse oximetry respiratory monitoring for assessment of acute childhood wheeze. Arch Dis Child 2022; 107:1083-1087. [PMID: 35940849 DOI: 10.1136/archdischild-2021-323390] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2021] [Accepted: 07/25/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE There is a lack of objective measures to assess children with acute wheezing episodes. Increased respiratory rate (RR) and pulsus paradoxus (PP) are recognised markers, but poorly recorded in practice. We examined whether they can be reliably assessed from a pulse oximeter plethysmogram ('pleth') trace and predict clinical outcome. PATIENTS AND METHODS We studied 44 children aged 1-7 years attending hospital with acute wheeze, following initial 'burst' bronchodilator therapy (BT), and used custom software to measure RR and assess PP from oximeter pleth traces. Traces were examined for quality, and the accuracy of the RR measurement was validated against simultaneous respiratory inductive plethysmography (RIP). RR and PP at 1 hour after BT were compared with clinical outcomes. RESULTS RR from pleth and RIP showed excellent agreement, with a mean difference (RIP minus pleth) of -0.5 breaths per minute (limits of agreement -3.4 to +2.3). 52% of 1 min epochs contained 10 s or more of pleth artefact. At 1 hour after BT, children who subsequently required intravenous bronchodilators had significantly higher RR (median (IQR) 63 (62-66) vs 43 (37-51) breaths per minute) than those who did not, but their heart rate and oxygen saturation were similar. Children with RR ≥55 per minute spent longer in hospital: median (IQR) 30 (22-45) vs 10 (7-21) hours. All children who subsequently required hospital admission had PP-analogous pleth waveforms 1 hour after BT. CONCLUSION RR can be reliably measured and PP detected from the pulse oximeter pleth trace in children with acute wheeze and both markers predict clinical outcome. TRIAL REGISTRATION NUMBER UKCRN15742.
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Affiliation(s)
- David Wertheim
- Faculty of Science, Engineering and Computing, Kingston University, Kingston, UK
| | - Oana Anton
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | - Catherine Olden
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
| | | | - Paul C Seddon
- Respiratory Care, Royal Alexandra Children's Hospital, University Hospitals Sussex NHS Foundation Trust, Brighton, UK
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11
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Moretti ME, Jegathisawaran J, Wahi G, Bayliss A, Kanani R, Pound CM, Sakran M, Parkin PC, Mahant S. Cost-effectiveness of Intermittent vs Continuous Pulse Oximetry Monitoring in Infants Hospitalized With Stabilized Bronchiolitis. JAMA Netw Open 2022; 5:e2243609. [PMID: 36416823 PMCID: PMC9685487 DOI: 10.1001/jamanetworkopen.2022.43609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Pulse oximetry is a noninvasive technology that is integral to the supportive care of hospitalized infants with bronchiolitis. A multicenter, randomized trial comparing the effectiveness of intermittent vs continuous pulse oximetry found similar length of hospital stay and safety outcomes, and greater nursing satisfaction, with intermittent monitoring. OBJECTIVES To evaluate the cost-effectiveness of intermittent vs continuous pulse oximetry in hospitalized infants with stabilized bronchiolitis. DESIGN, SETTING, AND PARTICIPANTS An economic evaluation concurrent with a randomized trial in community and tertiary children's hospitals in Ontario, Canada, was conducted using a probabilistic analysis. Patients were enrolled from November 1, 2016, to May 31, 2019. Data included infants aged 4 weeks to 24 months hospitalized with bronchiolitis, with or without supplemental oxygen, after stabilization. The cost-effectiveness analysis adopted a societal and health care system perspective and a time horizon from hospitalization to 15 days post-discharge. Patient level direct health care costs and indirect costs were included. Health resource use, costs, and clinical outcomes were obtained from trial data. Publicly available pricing resources were used to supplement costs. Ranges for sensitivity analysis were based on 95% confidence intervals of the trial data. All costs were reported in 2021 Canadian dollars. INTERVENTIONS Intermittent (every 4 hours) vs continuous pulse oximetry using an oxygen saturation target of 90% or higher. MAIN OUTCOMES AND MEASURES Costs and incremental costs. RESULTS Trial data from 229 infants (median [IQR] age, 4.0 [2.2-8.5] months; 136 boys [59.4%], 93 girls [40.6%]) were included. Mean societal costs per patient were $6879 (95% CI, $3393 to $12 317) in the intermittent and $7428 (95% CI, $1743 to $25 011) in the continuous group with a mean incremental cost of -$548 (95% CI, -$18 486 to $8105). Mean health care system costs per patient were $4195 (95% CI, $1191 to $9461) in the intermittent and $4716 (95% CI, $335 to $22 093) in the continuous group (incremental cost, -$520; 95% CI, -$18 286 to $7358). The mean effect measure of length of stay was similar between the 2 groups: 37.4 hours (95% CI, 1.0 to 137.7 hours) in the intermittent group and 38.5 hours (95% CI, 0 to 237.1 hours) in the continuous group. One-way sensitivity analyses on all variables revealed that the findings were robust and the incremental costs were not sensitive to the uncertainty within the defined ranges. CONCLUSIONS AND RELEVANCE In this prospective economic evaluation study, we found that costs were similar for intermittent and continuous pulse oximetry considering societal and health care perspectives. Given that clinical outcomes between monitoring strategies are comparable and that other practice considerations favor intermittent monitoring, these findings provide additional information that support the use of intermittent monitoring in hospitalized infants with stabilized bronchiolitis.
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Affiliation(s)
- Myla E. Moretti
- Clinical Trials Unit, Ontario Child Health Support Unit, The Hospital for Sick Children, Toronto, Ontario, Canada
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Jathishinie Jegathisawaran
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
| | - Gita Wahi
- Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
| | - Ann Bayliss
- Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Ronik Kanani
- Department of Pediatrics, University of Toronto, Ontario, Canada
- Department of Pediatrics, North York General Hospital, Toronto, Ontario, Canada
| | - Catherine M. Pound
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
| | - Mahmoud Sakran
- Department of Pediatrics, Lakeridge Health, Oshawa, and Queens University, Kingston
| | - Patricia C. Parkin
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
| | - Sanjay Mahant
- Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada
- Child Health Evaluative Sciences, The Hospital for Sick Children, Peter Gilgan Centre for Research and Learning, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Ontario, Canada
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12
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Schondelmeyer AC, Hayatghaibi S, Bettencourt AP. Weighing the Costs of Pulse Oximetry for Pediatric Bronchiolitis. JAMA Netw Open 2022; 5:e2243615. [PMID: 36416828 DOI: 10.1001/jamanetworkopen.2022.43615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Amanda C Schondelmeyer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
| | - Shireen Hayatghaibi
- James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Amanda P Bettencourt
- Department of Family and Community Health, University of Pennsylvania School of Nursing, Philadelphia
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13
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Bonafide CP, Xiao R, Schondelmeyer AC, Pettit AR, Brady PW, Landrigan CP, Wolk CB, Cidav Z, Ruppel H, Muthu N, Williams NJ, Schisterman E, Brent CR, Albanowski K, Beidas RS. Sustainable deimplementation of continuous pulse oximetry monitoring in children hospitalized with bronchiolitis: study protocol for the Eliminating Monitor Overuse (EMO) type III effectiveness-deimplementation cluster-randomized trial. Implement Sci 2022; 17:72. [PMID: 36271399 PMCID: PMC9587657 DOI: 10.1186/s13012-022-01246-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 10/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background Methods of sustaining the deimplementation of overused medical practices (i.e., practices not supported by evidence) are understudied. In pediatric hospital medicine, continuous pulse oximetry monitoring of children with the common viral respiratory illness bronchiolitis is recommended only under specific circumstances. Three national guidelines discourage its use for children who are not receiving supplemental oxygen, but guideline-discordant practice (i.e., overuse) remains prevalent. A 6-hospital pilot of educational outreach with audit and feedback resulted in immediate reductions in overuse; however, the best strategies to optimize sustainment of deimplementation success are unknown. Methods The Eliminating Monitor Overuse (EMO) trial will compare two deimplementation strategies in a hybrid type III effectiveness-deimplementation trial. This longitudinal cluster-randomized design will be conducted in Pediatric Research in Inpatient Settings (PRIS) Network hospitals and will include baseline measurement, active deimplementation, and sustainment phases. After a baseline measurement period, 16–19 hospitals will be randomized to a deimplementation strategy that targets unlearning (educational outreach with audit and feedback), and the other 16–19 will be randomized to a strategy that targets unlearning and substitution (adding an EHR-integrated clinical pathway decision support tool). The primary outcome is the sustainment of deimplementation in bronchiolitis patients who are not receiving any supplemental oxygen, analyzed as a longitudinal difference-in-differences comparison of overuse rates across study arms. Secondary outcomes include equity of deimplementation and the fidelity to, and cost of, each deimplementation strategy. To understand how the deimplementation strategies work, we will test hypothesized mechanisms of routinization (clinicians developing new routines supporting practice change) and institutionalization (embedding of practice change into existing organizational systems). Discussion The EMO trial will advance the science of deimplementation by providing new insights into the processes, mechanisms, costs, and likelihood of sustained practice change using rigorously designed deimplementation strategies. The trial will also advance care for a high-incidence, costly pediatric lung disease. Trial registration ClinicalTrials.gov,NCT05132322. Registered on November 10, 2021. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01246-z.
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Affiliation(s)
- Christopher P Bonafide
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA. .,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA. .,Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 206 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Amanda C Schondelmeyer
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, 45229, USA.,Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave ML 9016, Cincinnati, OH, 45229, USA
| | | | - Patrick W Brady
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave ML 9016, Cincinnati, OH, 45229, USA.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Christopher P Landrigan
- Division of General Pediatrics, Boston Children's Hospital, Enders 1, 300 Longwood Ave, Boston, MA, 02115, USA.,Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Courtney Benjamin Wolk
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, USA
| | - Zuleyha Cidav
- Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Halley Ruppel
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.,Department of Family and Community Health, School of Nursing, University of Pennsylvania, Philadelphia, USA
| | - Naveen Muthu
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, 2716 South Street, Philadelphia, PA, 19146, USA
| | - Nathaniel J Williams
- School of Social Work, Boise State University, 1910 W. University Drive, Boise, ID, 83725, USA.,Institute for the Study of Behavioral Health and Addiction, Boise State University, Boise, USA
| | - Enrique Schisterman
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, 206 Blockley Hall, 423 Guardian Drive, Philadelphia, PA, 19104-6021, USA
| | - Canita R Brent
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Kimberly Albanowski
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Children's Hospital of Philadelphia Hub for Clinical Collaboration, 3500 Civic Center Blvd, Philadelphia, PA, 19104, USA
| | - Rinad S Beidas
- Penn Implementation Science Center at the Leonard Davis Institute of Health Economics (PISCE@LDI), University of Pennsylvania, Philadelphia, USA.,Department of Psychiatry, Perelman School of Medicine, University of Pennsylvania, 3535 Market Street, Philadelphia, PA, 19104, USA.,Department of Medical Ethics and Health Policy, Perelman School of Medicine, Philadelphia, USA.,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, 3600 Civic Center Boulevard, 8th Floor, Philadelphia, PA, 19104, USA.,Penn Medicine Nudge Unit, University of Pennsylvania Health System, Philadelphia, USA.,Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, USA.,Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
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14
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Dalziel SR, Haskell L, O'Brien S, Borland ML, Plint AC, Babl FE, Oakley E. Bronchiolitis. Lancet 2022; 400:392-406. [PMID: 35785792 DOI: 10.1016/s0140-6736(22)01016-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 03/27/2022] [Accepted: 05/26/2022] [Indexed: 02/06/2023]
Abstract
Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.
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Affiliation(s)
- Stuart R Dalziel
- Department of Surgery, The University of Auckland, Auckland, New Zealand; Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.
| | - Libby Haskell
- Department of Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand; Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; School of Nursing, Curtin University, Perth, WA, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, WA, Australia; Division of Paediatrics, School of Medicine, University of Western Australia, Perth, WA, Australia; Division of Emergency Medicine, School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada; Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada; Emergency Department, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia; Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
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15
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Natarajan E, Florin TA, Constantinou C, Aronson PL. What Is the Role of Shared Decision-Making With Parents of Children With Bronchiolitis? Hosp Pediatr 2022; 12:e50-e53. [PMID: 34972216 PMCID: PMC9667985 DOI: 10.1542/hpeds.2021-006245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Affiliation(s)
- Eesha Natarajan
- Pediatric Residency Program, Department of Pediatrics,Address correspondence to Eesha Natarajan, MBBS, Department of Pediatrics, Yale New Haven Hospital, 1 Park St, West Pavilion, 7th floor, New Haven, CT 06504. E-mail:
| | - Todd A. Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Christina Constantinou
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and of Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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16
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Gill PJ, Anwar MR, Kornelsen E, Parkin P, Mahood Q, Mahant S. Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis. Cochrane Database Syst Rev 2021; 12:CD013552. [PMID: 34852398 PMCID: PMC8635777 DOI: 10.1002/14651858.cd013552.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The main focus of treatment for children hospitalised with bronchiolitis is supportive, including oxygen supplementation, respiratory support, and fluid therapy. Up to half of infants hospitalised with bronchiolitis require non-oral fluid therapy due to dehydration or concerns related to the safety of oral feeding. The two main modalities used for non-oral fluid therapy are parenteral (intravenous (IV)) and enteral tube (nasogastric (NG) or orogastric (OG)). However, it is not known which mode is optimal in young children. OBJECTIVES To systematically review randomised clinical trials (RCTs) of the effectiveness and safety of parenteral and enteral tube fluid therapy for children under two years of age hospitalised with bronchiolitis. SEARCH METHODS We conducted a search of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, CINAHL, Web of Science, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 March 2021. We handsearched conference proceedings, conducted forward and backward searching of citation lists of relevant articles, and contacted experts. SELECTION CRITERIA We included RCTs and quasi-RCTs of children aged up to two years admitted to hospital with a clinical diagnosis of bronchiolitis who required fluid therapy. The trials compared enteral tube fluid therapy with parenteral fluid therapy. The primary outcome was difference in length of hospital stay in hours after each non-oral fluid therapy modality. As actual time of discharge can be impacted by various factors, we also assessed theoretical length of stay (i.e. time when a patient is safe for discharge). We assessed several secondary outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS: The searches yielded 615 unique records, of which four articles underwent full-text screening. We included two trials (810 children). Oakley 2013 was an open, non-blinded RCT of infants aged two to 12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons. The trial enrolled 759 children, of which 381 were randomised to NG tube therapy and 378 to IV therapy. Risk of bias was low in most domains. Kugelman 2013 was an open, non-blinded RCT that enrolled infants aged less than six months with a clinical diagnosis of "moderate bronchiolitis" at a single hospital in Israel. The study enrolled 51 infants, of which 31 were assigned to NG or OG tube therapy and 20 to IV therapy. Risk of bias was unclear in most domains. The application of enteral tube fluid therapy compared to IV fluid therapy probably makes little to no difference for actual length of hospital stay (mean difference (MD) 6.8 hours, 95% confidence interval (CI) -4.7 to 18.4 hours; 2 studies, 810 children, moderate certainty evidence). There was also little to no difference for theoretical length of stay (MD 4.4 hours, 95% CI -3.6 to 12.4 hours; 2 studies, 810 children, moderate certainty evidence). For the secondary outcomes, enteral tube fluid therapy probably makes little to no difference for time to resume full oral feeding compared to IV fluid therapy (MD 2.8 hours, 95% CI -3.6 to 9.2 hours; 2 studies, 810 children, moderate certainty evidence). The use of enteral tube for fluid therapy probably results in a large increase in the success of insertion of fluid modality at first attempt (risk ratio (RR) 1.52, 95% CI 1.36 to 1.69; 1 study, 617 children, moderate certainty evidence), and probably largely reduces the chances of change in fluid therapy modality (RR 0.52, 95% CI 0.38 to 0.71; 1 study, 759 children, moderate certainty evidence) compared to IV fluid. Oakley 2013 reported 47 local complication events after discharge in the IV fluid group compared to 30 events in the NG tube group. They also evaluated parental satisfaction, which was high with both modalities. Enteral tube fluid therapy makes little to no difference to the duration of oxygen supplementation (MD 2.2 hours, 95% CI -5.0 to 9.5 hours; 2 studies, 810 children, moderate certainty evidence). Compared with the IV fluid therapy group, there was a 17% relative reduction in the number of intensive care unit admissions (RR 0.83, 95% CI 0.47 to 1.46; 1 study, 759 children, moderate certainty evidence) and a 19% relative reduction in number of readmissions to hospital (RR 0.81, 95% CI 0.33 to 2.04; 1 study, 678 children, moderate certainty evidence) in the enteral tube fluid therapy group. Adverse events were uncommon in both trials, with likely little to no differences between groups. AUTHORS' CONCLUSIONS Based on two RCTs, enteral tube feeding likely results in little to no difference in length of hospital stay compared with the IV fluid group. However, enteral tube fluid therapy likely results in a large increase in the success of insertion of fluid modality at first attempt, and a large reduction in change in modality of fluid therapy. It also probably reduces local complications compared to the IV fluid group. Despite bronchiolitis being one of the most prevalent childhood conditions, we identified only two studies with under 1000 participants in total, which highlights the need for multicentre trials. Future studies should explore type of fluid administered, parent-reported outcomes and preferences, and the role of shared decision-making.
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Affiliation(s)
- Peter J Gill
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluation Sciences, The Hospital for Sick Children (SickKids), Toronto, Canada
| | | | - Patricia Parkin
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Quenby Mahood
- The Hospital for Sick Children (SickKids), Toronto, Canada
| | - Sanjay Mahant
- Pediatric Outcomes Research Team, Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, SickKids Research Institute, Toronto, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
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Schondelmeyer AC, Jenkins AM, Vaughn LM, Brady PW. Family Perspectives on Continuous Monitor Use in a Children's Hospital: A Qualitative Study. Hosp Pediatr 2021; 11:hpeds.2021-005949. [PMID: 34808668 DOI: 10.1542/hpeds.2021-005949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Alarms from continuous cardiorespiratory and pulse oximetry monitors may contribute to parental anxiety and poor sleep during hospitalization, yet families also may find monitoring reassuring. Our objective was to understand how families perceive the utility, benefits, and harms of continuous monitoring. METHODS In this single-center qualitative study, we used semistructured interviews and direct observation. We enrolled families of patients of a variety of ages and clinical diagnoses. We extracted patient demographic information (age, diagnosis) from the health record. Semistructured interviews were recorded and transcribed. Detailed field notes were taken during observations. We used an inductive thematic approach to develop and refine codes that informed the development of themes. RESULTS We recruited 24 families and conducted 23 interviews and 9 observation sessions. Respiratory conditions (eg, bronchiolitis, asthma) were the most common reason for hospitalization. The hospitalized children covered a range of ages: <4 weeks (16%), 4 weeks to 6 months (20%), 7 months to 5 years (44%), and >5 years (20%); 55% had previously been hospitalized. Families expressed varying degrees of understanding the utility of monitors and often conducted their own assessments before notifying staff about alarms. Families expected monitoring, including negative effects like sleep disruption, as part of hospitalization. Families perceived the benefit of monitoring in context of previous hospital experiences, often seeing less benefit and worrying less about alarms in subsequent hospitalizations. CONCLUSIONS Family members continue to find reassurance from cardiorespiratory monitoring despite evidence that it offers limited benefit outside of the ICU setting. Parental perspectives should be addressed in future deimplementation efforts.
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Affiliation(s)
- Amanda C Schondelmeyer
- Departments of Pediatrics
- Divisions of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ashley M Jenkins
- Departments of Pediatrics
- Internal Medicine, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | | | - Patrick W Brady
- Departments of Pediatrics
- Divisions of Hospital Medicine
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Ralston SL, House SA. Deimplementing Continuous Pulse Oximetry in Patients With Bronchiolitis-What Are We Waiting For? JAMA Netw Open 2021; 4:e2123057. [PMID: 34473263 DOI: 10.1001/jamanetworkopen.2021.23057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Samantha A House
- Children's Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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Intermittent vs. Continuous Pulse Oximetry in Infants Hospitalized with Bronchiolitis. Am J Nurs 2021; 121:55. [PMID: 34819476 DOI: 10.1097/01.naj.0000767820.65687.38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
According to this study: Clinical outcomes were similar with intermittent and continuous pulse oximetry in infants who had stabilized bronchiolitis, providing support for standard use of intermittent monitoring in this population.
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Gill PJ, Anwar MR, Thavam T, Hall M, Rodean J, Kaiser SV, Srivastava R, Keren R, Mahant S. Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals. JAMA Netw Open 2021; 4:e2117816. [PMID: 34309667 PMCID: PMC8314139 DOI: 10.1001/jamanetworkopen.2021.17816] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
IMPORTANCE Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. OBJECTIVES To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. MAIN OUTCOMES AND MEASURES The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. RESULTS There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). CONCLUSIONS AND RELEVANCE This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.
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Affiliation(s)
- Peter J. Gill
- Department of Pediatrics, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Mohammed Rashidul Anwar
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Thaksha Thavam
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas
| | | | - Sunitha V. Kaiser
- Department of Pediatrics and Department of Epidemiology and Biostatistics, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
| | - Rajendu Srivastava
- Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
- Healthcare Delivery Institute, Intermountain Healthcare, Salt Lake City, Utah
| | - Ron Keren
- Department of Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sanjay Mahant
- Department of Pediatrics, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Canada
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