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Freiman EC, Monuteaux MC, Michelson KA. Variation and Drivers of Costs for Emergency Department Visits Among Children in 8 States. Hosp Pediatr 2024; 14:258-264. [PMID: 38505934 PMCID: PMC11015896 DOI: 10.1542/hpeds.2023-007417] [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] [Accepted: 01/17/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE To describe variation in costs for emergency department (ED) visits among children and to assess hospital and regional factors associated with costs. METHODS Cross-sectional study of all ED encounters among children under 18 years in 8 states from 2014 to 2018. The primary outcome was each hospital's mean inflation-adjusted ED costs. We evaluated variability in costs between hospitals and determined factors associated with costs using hierarchical linear models at the state, region, and hospital levels. Models adjusted for pediatric case mix, regional wages, Medicaid share, trauma status, critical access status, ownership, and market competitiveness. RESULTS We analyzed 22.9 million ED encounters across 713 hospitals. The median ED-level cost was $269 (range 99-1863). There was a 5.1-fold difference in median ED-level costs between the lowest- and highest-cost regions (range 119-605). ED-level costs were associated with case mix index (+38% per 10% increase, 95% confidence interval [CI] 30 to 47); wages [+7% per 10% increase, 95% CI 5 to 9]); critical access (adjusted costs, +24%, 95% CI 13 to 35); for profit status (-20%, 95% CI -26 to -14) compared with nonprofit, lowest trauma designation (+17%, 95% CI 5 to 30); teaching hospital status (+7%, 95% CI 1 to 14); highest number of inpatient beds (+13%, 95% CI 4 to 23); and Medicaid share versus quarter (Q)1 (Q2: -12%, 95% CI -18 to -7; Q3: -13%, 95% CI -19 to -7; Q4: -11%, 95% CI -17 to -4). CONCLUSIONS Our results suggest nonclinical factors are important drivers of pediatric health care costs.
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Affiliation(s)
- Eli C Freiman
- Division of Emergency Medicine, Newton Wellesley Hospital, Newton, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kenneth A Michelson
- Division of Emergency Medicine, Lurie Children's Hospital of Chicago, Chicago, Illinois
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2
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Shuster B, Switzer BE, Krishnasamy M, Garimella R, Vu T, Tierney D, Port C. Safely Shifting MRIs for Seizure Evaluation to the Outpatient Setting. Hosp Pediatr 2023; 13:1077-1086. [PMID: 37960877 DOI: 10.1542/hpeds.2023-007333] [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: 11/15/2023]
Abstract
BACKGROUND AND OBJECTIVES When a patient is admitted for seizure-like activity, in addition to obtaining a thorough history and physical exam, the evaluation may include a neurology consultation, EEG, and brain MRI. The cost of an inpatient MRI is significant and only 2% of MRIs yield clinically significant findings. At our institution, there was a 20% increase in patients undergoing inpatient MRI from 2018 to 2020. Our aim: Decrease the percentage of patient encounters receiving inpatient brain MRIs for seizure evaluation from 50% to 40% in 6 months by safely shifting MRIs to the outpatient setting. METHODS Initially, provider variability in ordering practices of MRIs was analyzed. Stakeholders were gathered and a local guideline was developed to standardize MRI utilization. A process map was created and highlighted barriers to obtaining an outpatient MRI. A new standard process was developed that streamlined and automated processes, and reduced delays and reliance on patients' families. RESULTS Since implementation of the new clinical guideline, the percentage of inpatient MRIs ordered for patient encounters presenting with seizures and seizure-like episodes decreased from a mean of 50% to 26%. Significant reductions occurred for patients with complex febrile seizures, provoked but afebrile seizures, and unprovoked seizures. The MRI guideline recommendations were followed in 93% of encounters in the final 12 months. None of the patients who underwent outpatient MRI required readmission for acute findings. CONCLUSIONS In this project, the percentage of inpatient MRIs was safely decreased with the implementation of a clinical guideline and standardized process.
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Affiliation(s)
- Brooke Shuster
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Barbara E Switzer
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Meenu Krishnasamy
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Rijutha Garimella
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Thuy Vu
- Pediatric Specialists of Virginia, Fairfax, Virginia
| | - Daniel Tierney
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
| | - Courtney Port
- Department of Pediatrics, Inova Children's Hospital, Falls Church, Virginia
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Navanandan N, Thompson T, Pyle L, Florin TA. Defining Treatment Response for Clinical Trials of Pediatric Acute Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1450-1458.e1. [PMID: 36621607 PMCID: PMC10164688 DOI: 10.1016/j.jaip.2022.12.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 12/12/2022] [Accepted: 12/19/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND An agreed-upon definition of treatment response for clinical trials of pediatric acute asthma does not exist, limiting meaningful comparisons among therapeutic interventions and advances in asthma management. OBJECTIVE To develop a consensus definition of treatment response for clinical trials of pediatric acute asthma. METHODS A multidisciplinary panel of 22 experts participated in a Web-based modified Delphi process to achieve consensus on a definition of treatment response. Round 1 consisted of closed- and open-ended questions in which panelists ranked measures of treatment response developed by literature review, suggested additional measures, and explained their responses. In rounds 2 and 3, panelists reviewed summary statistics of the panel's rating from prior rounds and reconsidered their rankings. In round 3, pairwise ranking was performed to determine the ranked importance of components. Consensus was defined as 70% or greater agreement among panelists choosing Likert-scale values of 1 to 6 (extremely unimportant to extremely important) and an interquartile range less than 2. RESULTS Drawing on results from the expert panel, we developed a definition of treatment response that includes Clinical Severity Score, need for additional therapies, and hospitalization. Clinical Severity Score encompassed most ranked criteria (eg, respiratory distress, wheeze) for a treatment response definition. Panelists recommended that a valid and pragmatic severity score be used consistently across institutions. Panelists also achieved consensus on the top 10 criteria that appropriately classify need for hospitalization. CONCLUSIONS This consensus definition of treatment response can be used in clinical trials of children with acute asthma to standardize outcome measurement and report meaningful outcomes.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
| | - Talia Thompson
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Laura Pyle
- Child Health Biostatistics Core, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colo
| | - Todd A Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Ill
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Xie SS, Guarnieri KM, Courter JD, Liu C, Ruddy RM, Risma KA. Predictors of Acute Care Reutilization in Pediatric Patients With Amoxicillin-Associated Reactions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2958-2966.e3. [PMID: 35872215 DOI: 10.1016/j.jaip.2022.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/26/2022] [Accepted: 06/20/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Amoxicillin-associated reactions (AARs) contribute to substantial health care utilization, with a reutilization rate of 10% in pediatric emergency department (ED) and urgent care (UC) settings. OBJECTIVE To identify predictors of ED/UC reutilization by examining patients' clinical features and providers' management of AARs. METHODS Through a retrospective chart review of 668 patients presenting with AARs over 2 years to the pediatric ED/UC, we examined clinical features associated with ED/UC reutilization, including rash phenotype, systemic symptoms (fever, angioedema, joint involvement, gastrointestinal symptoms), and providers' management (pharmacologic treatment and counseling). We then constructed a statistical model to predict ED/UC reutilization using stepwise backward model selection. RESULTS ED/UC reutilizers were more likely to be male (P = .008) and have fever (P = .0001), angioedema (P < .0001), joint involvement (P < .0001), and gastrointestinal symptoms (P = .0001) during their AAR course. Rash phenotypes differed between groups (P < .0001), as ED/UC reutilizers more frequently exhibited urticaria. However, there were no differences in clinical management between groups, including pharmacologic recommendations, at the initial ED/UC encounter. In addition, our statistical model identified younger patients <2 years of age as more likely to reutilize ED/UC resources if providers did not document specific return precautions (odds ratio, 3.6; 95% confidence interval, 1.7-7.7). CONCLUSION Recognition of clinical features and treatment gaps associated with ED/UC reutilization will guide interventions to optimize care in children presenting with AARs, such as improved anticipatory guidance and early allergy consultation. Prospective studies are needed to determine whether these interventions will reduce ED/UC reutilization and facilitate timely allergy testing.
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Affiliation(s)
- Susan S Xie
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Katharine M Guarnieri
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua D Courter
- Division of Pharmacy, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Richard M Ruddy
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Risma
- Division of Allergy and Immunology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
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5
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Stephens JR, Hall M, Molloy MJ, Markham JL, Cotter JM, Tchou MJ, Aronson PL, Steiner MJ, McCoy E, Collins ME, Shah SS. Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures. J Hosp Med 2022; 17:327-341. [PMID: 35560723 PMCID: PMC11309806 DOI: 10.1002/jhm.12833] [Citation(s) in RCA: 2] [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: 12/11/2021] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. OBJECTIVES (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. OUTCOME MEASURES Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. RESULTS We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. CONCLUSIONS Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.
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Affiliation(s)
- John R. Stephens
- Department of Pediatrics, North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matt Hall
- Children’s Hospital Association, Overland Park, Kansas, USA
| | - Matthew J. Molloy
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jillian M. Cotter
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J. Tchou
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J. Steiner
- Department of Pediatrics, North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
| | - Megan E. Collins
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Abstract
OBJECTIVES The aims of the study were to estimate testing and treatment rates among pediatric low-acuity emergency department (ED) visits and to compare testing and treatment patterns at general and pediatric-specific EDs. METHODS We performed a cross-sectional study of triage level 4 or 5 pediatric visits from a complex survey of nonfederal US EDs from 2008 to 2017. We analyzed demographics, vital signs, disposition, testing, and treatment. We calculated proportions for each data element and used χ2 tests to determine differences between general and pediatric EDs. RESULTS There were an estimated 306.2 million pediatric visits with 129.1 million acuity level 4 or 5 visits (57.2%; 95% confidence interval, 55.4%-58.9%), with diagnostic testing performed in 47.1% and medications administered in 69.6% of the visits. Most low-acuity visits (82.0%) were to general EDs. Tests performed more frequently in general EDs compared with pediatric EDs included radiographs (25.8% vs 15.7%, P < 0.01), complete blood count (6.4% vs 3.9%, P < 0.01), electrolytes (11.6% vs 3.7%, P < 0.01), and glucose (2.0% vs 0.9%, P < 0.01). Ultrasound was used less frequently in general EDs (0.5 vs 0.7, P < 0.01). There were similar rates of intravenous fluid and overall medication administration and a higher proportion of patients receiving antibiotics in general EDs (28.7% vs 23.8%, P < 0.01). CONCLUSIONS More than half of pediatric visits to the ED are low acuity. Although general EDs relied on more imaging, blood testing and antibiotics, and pediatric EDs on ultrasound, overall resource utilization was high in this population across both ED types and can likely be reduced.
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Affiliation(s)
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jennifer R Marin
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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Roskind CG, Schnadower D, Olsen CS, Casper TC, Tarr PI, O’Connell KJ, Levine AC, Poonai N, Schuh S, Rogers AJ, Bhatt SR, Gouin S, Mahajan P, Vance C, Hurley K, Farion KJ, Sapien RE, Freedman SB, Freedman SB. Oral Ondansetron Administration in Children Seeking Emergency Department Care for Acute Gastroenteritis: A Patient-Level Propensity-Matched Analysis. Ann Emerg Med 2022; 79:66-74. [PMID: 34389195 PMCID: PMC8712362 DOI: 10.1016/j.annemergmed.2021.06.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 05/28/2021] [Accepted: 06/01/2021] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVE This study aimed to explore oral ondansetron usage and impact on outcomes in clinical practice. METHODS This observational study was a planned secondary analysis of 2 trials conducted in 10 US and 6 Canadian institutions between 2014 and 2017. Children 3 to 48 months old with gastroenteritis and ≥3 episodes of vomiting in the 24 hours preceding emergency department (ED) presentation were included. Oral ondansetron was administered at the discretion of the provider. The principal outcomes were intravenous fluid administration and hospitalization at the index visit and during the subsequent 72 hours and diarrhea and vomiting frequency during the 24 hours following the ED visit. RESULTS In total, 794 children were included. The median age was 16.0 months (interquartile range 10.0 to 26.0), and 50.1% (398/794) received oral ondansetron. In propensity-adjusted analysis (n=528), children administered oral ondansetron were less likely to receive intravenous fluids at the index visit (adjusted odds ratio [aOR] 0.50; 95% confidence interval [CI] 0.29 to 0.88). There were no differences in the frequencies of intravenous fluid administration within the first 72 hours (aOR 0.65; 95% CI 0.39 to 1.10) or hospitalization at the index visit (aOR 0.31; 95% CI 0.09 to 1.10) or the subsequent 72 hours (aOR 0.52; 95% CI 0.21 to 1.28). Episodes of vomiting (aRR 0.86; 95% CI 0.63 to 1.19) and diarrhea (aRR 1.11; 95% CI 0.93 to 1.32) during the 24 hours following ED discharge also did not differ. CONCLUSION Among preschool-aged children with gastroenteritis seeking ED care, oral ondansetron administration was associated with a reduction in index ED visit intravenous fluid administration; it was not associated with intravenous fluids administered within 72 hours, hospitalization, or vomiting and diarrhea in the 24 hours following discharge.
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Affiliation(s)
- Cindy G. Roskind
- Department of Emergency Medicine, Columbia University Vagelos College of Physicians & Surgeons, New York, NY, USA
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, and Department of Pediatrics, University of Cincinnati College of Medicine, OHIO, USA
| | - Cody S. Olsen
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - T. Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Phillip I. Tarr
- Division of Gastroenterology, Hepatology, & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Karen J. O’Connell
- Division of Emergency Medicine, Children's National Health System, Department of Pediatrics, The George Washington School of Medicine and Health Sciences, Washington, DC, USA
| | - Adam C. Levine
- Department of Emergency Medicine, Rhode Island Hospital/Hasbro Children's Hospital and Brown University, Providence, RI, USA
| | - Naveen Poonai
- Department of Pediatrics, Internal Medicine, Epidemiology & Biostatistics, Schulich School of Medicine and Dentistry, London, Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto and Research Institute, Hospital for Sick Children, Toronto, Canada
| | - Alexander J. Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Seema R. Bhatt
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Serge Gouin
- Department of Pediatric Emergency Medicine, Centre Hospital Universitaire (CHU) Ste-Justine, Université de Montréal, Montreal, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, USA, and Division of Emergency Medicine, Department of Pediatrics, Children’s Hospital of Michigan, Wayne State University, Detroit, MI, USA
| | - Cheryl Vance
- Departments of Pediatrics and Emergency Medicine, University of California, Davis, School of Medicine, Sacramento, CA, USA
| | - Katrina Hurley
- Division of Pediatric Emergency Medicine, IWK Health Center, Halifax, NS, Canada
| | - Ken J. Farion
- Departments of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada
| | - Robert E. Sapien
- Department of Emergency Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hudgins JD, Neuman MI, Monuteaux MC, Porter J, Nelson KA. Provision of Guideline-Based Pediatric Asthma Care in US Emergency Departments. Pediatr Emerg Care 2021; 37:507-512. [PMID: 30624420 DOI: 10.1097/pec.0000000000001706] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES National guidelines for routine pediatric acute asthma care recommend providing corticosteroids, and discourage routinely obtaining chest radiographs (CXRs) and using antibiotics. We examined rates of adherence to all 3 of these aspects during emergency department (ED) visits and compared performance between pediatric and general EDs. METHODS Using the National Hospital Ambulatory Medical Care Survey, we included all nontransfer ED visits for patients younger than 19 years with a diagnosis of asthma and treatment with albuterol from 2005 to 2015. Guideline-based care, defined as (1) corticosteroids, (2) no antibiotics, and (3) no CXR, was assessed for each visit. Hospitals were categorized as pediatric or general and compared according to rates of guideline-based care. Multivariable analyses were used to identify demographic and hospital-level characteristics associated with guideline-based care. RESULTS More than 7 million ED visits met eligibility criteria. Antibiotic provision and CXR acquisition were significantly higher in general EDs (20% vs 11%, 40% vs 26%, respectively), while steroid provision was similar (63% vs 62%). Overall, 34% of visits involved guideline-based care, with a higher rate for pediatric EDs compared with general EDs (42% to 31%). Visit at a pediatric ED (odds ratio, 1.62 [confidence interval 1.17-2.25]) and black race (odds ratio, 1.48 [confidence interval 1.07-2.02]) were independently associated with guideline-based care in a multivariate analysis. CONCLUSIONS Guideline-based care was more common in pediatric EDs, although only one-third of all pediatric-age visits met the definition of guideline-based care. Future policy and education efforts to reduce unnecessary antibiotic and CXR use for children with asthma are warranted.
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Affiliation(s)
- Joel D Hudgins
- From the Division of Emergency Medicine, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA
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9
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Baker AH, Eisenberg M. Gastroenteritis Care in the US and Canada: Can Comparative Analysis Improve Resource Use? Pediatrics 2021; 147:peds.2021-050436. [PMID: 34016657 DOI: 10.1542/peds.2021-050436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Alexandra H Baker
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and
| | - Matthew Eisenberg
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts; and.,Department of Pediatrics, Harvard Medical School, Harvard University, Boston, Massachusetts
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10
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Freedman SB, Roskind CG, Schuh S, VanBuren JM, Norris JG, Tarr PI, Hurley K, Levine AC, Rogers A, Bhatt S, Gouin S, Mahajan P, Vance C, Powell EC, Farion KJ, Sapien R, O'Connell K, Poonai N, Schnadower D. Comparing Pediatric Gastroenteritis Emergency Department Care in Canada and the United States. Pediatrics 2021; 147:e2020030890. [PMID: 34016656 PMCID: PMC8785749 DOI: 10.1542/peds.2020-030890] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Between-country variation in health care resource use and its impact on outcomes in acute care settings have been challenging to disentangle from illness severity by using administrative data. METHODS We conducted a preplanned analysis employing patient-level emergency department (ED) data from children enrolled in 2 previously conducted clinical trials. Participants aged 3 to <48 months with <72 hours of gastroenteritis were recruited in pediatric EDs in the United States (N = 10 sites; 588 participants) and Canada (N = 6 sites; 827 participants). The primary outcome was an unscheduled health care provider visit within 7 days; the secondary outcomes were intravenous fluid administration and hospitalization at or within 7 days of the index visit. RESULTS In adjusted analysis, unscheduled revisits within 7 days did not differ (adjusted odds ratio [aOR]: 0.72; 95% confidence interval (CI): 0.50 to 1.02). At the index ED visit, although participants in Canada were assessed as being more dehydrated, intravenous fluids were administered more frequently in the United States (aOR: 4.6; 95% CI: 2.9 to 7.1). Intravenous fluid administration rates did not differ after enrollment (aOR: 1.4; 95% CI: 0.7 to 2.8; US cohort with Canadian as referent). Overall, intravenous rehydration was higher in the United States (aOR: 3.8; 95% CI: 2.5 to 5.7). Although hospitalization rates during the 7 days after enrollment (aOR: 1.1; 95% CI: 0.4 to 2.6) did not differ, hospitalization at the index visit was more common in the United States (3.9% vs 2.3%; aOR: 3.2; 95% CI: 1.6 to 6.8). CONCLUSIONS Among children with gastroenteritis and similar disease severity, revisit rates were similar in our 2 study cohorts, despite lower rates of intravenous rehydration and hospitalization in Canadian-based EDs.
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Affiliation(s)
- Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Departments of Pediatrics and Emergency Medicine, Alberta Children's Hospital and Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada;
| | - Cindy G Roskind
- Department of Emergency Medicine, Medical Center, Columbia University, New York, New York
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Toronto, Ontario
| | - John M VanBuren
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Jesse G Norris
- Department of Pediatrics, School of Medicine, University of Utah, Salt Lake City, Utah
| | - Phillip I Tarr
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, School of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Katrina Hurley
- Department of Emergency Medicine, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Adam C Levine
- Department of Emergency Medicine, Hasbro Children's Hospital, Rhode Island Hospital and Brown University, Providence, Rhode Island
| | - Alexander Rogers
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Seema Bhatt
- Division of Emergency Medicine, Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Serge Gouin
- Department of Pediatrics, Faculty of Medicine, Université de Montréal, Montréal, Quebec, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Cheryl Vance
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California, Davis, Sacramento, California
| | - Elizabeth C Powell
- Department of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ken J Farion
- Division of Emergency Medicine, Department of Pediatrics, Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Robert Sapien
- Department of Emergency Medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| | - Karen O'Connell
- Departments of Pediatrics and Emergency Medicine, School of Medicine and Health Sciences, George Washington University and Children's National Hospital, Washington, DC; and
| | - Naveen Poonai
- Departments of Paediatrics, Internal Medicine, and Epidemiology and Biostatistics, Schulich School of Medicine & Dentistry, London, Ontario, Canada
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Predicting Severe Asthma Exacerbations in Children: Blueprint for Today and Tomorrow. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2619-2626. [PMID: 33831622 DOI: 10.1016/j.jaip.2021.03.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Severe asthma exacerbations are the primary cause of morbidity and mortality in children with asthma. Accurate prediction of children at risk for severe exacerbations, defined as those requiring systemic corticosteroids, emergency department visit, and/or hospitalization, would considerably reduce health care utilization and improve symptoms and quality of life. Substantial progress has been made in identifying high-risk exacerbation-prone children. Known risk factors for exacerbations include demographic characteristics (ie, low income, minority race/ethnicity), poor asthma control, environmental exposures (ie, aeroallergen exposure/sensitization, concomitant viral infection), inflammatory biomarkers, genetic polymorphisms, and markers from other "omic" technologies. The strongest risk factor for a future severe exacerbation remains having had one in the previous year. Combining risk factors into composite scores and use of advanced predictive analytic techniques such as machine learning are recent methods used to achieve stronger prediction of severe exacerbations. However, these methods are limited in prediction efficiency and are currently unable to predict children at risk for impending (within days) severe exacerbations. Thus, we provide a commentary on strategies that have potential to allow for accurate and reliable prediction of children at risk for impending exacerbations. These approaches include implementation of passive, real-time monitoring of impending exacerbation predictors, use of population health strategies, prediction of severe exacerbation responders versus nonresponders to conventional exacerbation management, and considerations for preschool-age children who can be especially high risk. Rigorous prediction and prevention of severe asthma exacerbations is needed to advance asthma management and improve the associated morbidity and mortality.
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Lopez MA, Yu X, Walder A, Kowalkowski MA, Colvin JD, Raphael JL. Resource Use by Hospital Type for Frequent Inpatient Pediatric Conditions. Hosp Pediatr 2021; 11:287-292. [PMID: 33619079 DOI: 10.1542/hpeds.2020-0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Children's hospitals (CHs) deliver care to underserved, critically ill, and medically complex patients. However, non-CHs care for the majority of children with frequently occurring conditions. In this study, we aimed to examine resource use across hospitals where children receive care for frequent inpatient conditions. METHODS This was a cross-sectional, observational analysis of pediatric hospitalizations for 8 frequent inpatient conditions (pneumonia, asthma, bronchiolitis, mood disorders, appendicitis, epilepsy, skin and soft tissue infections, and fluid and electrolyte disorders) in the 2016 Kids' Inpatient Database. Primary outcomes were median length of stay (LOS) and median total cost. The primary independent variable was hospital type: nonchildren's, nonteaching; nonchildren's, teaching (NCT); and freestanding CHs. Multivariable linear regression was used to assess differences in mean LOS and costs. RESULTS There were 354 456 pediatric discharges for frequent inpatient conditions. NCT hospitals cared for more than one-half of all frequent inpatient conditions. CHs and NCT hospitals cared for the majority of patients with higher illness severity and medical complexity. After controlling for patient and hospital factors, discharges for frequent inpatient conditions at CHs had 0.48% longer mean LOS and 61% greater costs compared with NCT hospitals (P < .01). CONCLUSIONS CHs revealed higher estimated costs in caring for frequent inpatient conditions despite controlling for patient- and hospital-level factors but also cared for higher illness severity and medical complexity. Further research is warranted to explore whether we lack sufficient measures to control for patient-level factors and whether higher costs are justified by the specialized care at CHs.
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Affiliation(s)
- Michelle A Lopez
- Department of Pediatrics, and .,Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, Texas
| | - Xian Yu
- Department of Medicine, Health Services Research
| | | | - Marc A Kowalkowski
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina; and
| | - Jeffrey D Colvin
- Department of Pediatrics, Children's Mercy Hospital and Clinics and School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jean L Raphael
- Department of Pediatrics, and.,Center for Child Health Policy and Advocacy, Baylor College of Medicine, Houston, Texas
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Jang H, Ozkaynak M, Ayer T, Sills MR. Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma. Pediatr Emerg Care 2021; 37:e42-e47. [PMID: 30281550 DOI: 10.1097/pec.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.
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Affiliation(s)
- Hoon Jang
- From the Science and Technology Policy Institute, Sejong, South Korea
| | - Mustafa Ozkaynak
- School of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
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Abstract
Supplemental Digital Content is available in the text. Variability exists in the management of childhood syncope as clinicians balance resource utilization with the need to identify serious diseases. Limited evidence exists regarding the long-term impact of evidence-based guidelines (EBGs) on clinical practices. This study’s objective was to measure long-term changes in the management of syncope after implementing a syncope EBG in a single pediatric emergency department following the redistribution of resources to facilitate compliance over time.
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Schinkelshoek G, Borensztajn DM, Zachariasse JM, Maconochie IK, Alves CF, Freitas P, Smit FJ, van der Lei J, Steyerberg EW, Greber-Platzer S, Moll HA. Management of children visiting the emergency department during out-of-office hours: an observational study. BMJ Paediatr Open 2020; 4:e000687. [PMID: 32984551 PMCID: PMC7493126 DOI: 10.1136/bmjpo-2020-000687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 06/11/2020] [Accepted: 06/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The aim was to study the characteristics and management of children visiting the emergency department (ED) during out-of-office hours. METHODS We analysed electronic health record data from 119 204 children visiting one of five EDs in four European countries. Patient characteristics and management (diagnostic tests, treatment, hospital admission and paediatric intensive care unit admission) were compared between children visiting during office hours and evening shifts, night shifts and weekend day shifts. Analyses were corrected for age, gender, Manchester Triage System urgency, abnormal vital signs, presenting problems and hospital. RESULTS Patients presenting at night were younger (median (IQR) age: 3.7 (1.4-8.2) years vs 4.8 (1.8-9.9)), more often classified as high urgent (16.3% vs 9.9%) and more often had ≥2 abnormal vital signs (22.8% vs 18.1%) compared with office hours. After correcting for disease severity, laboratory and radiological tests were less likely to be requested (adjusted OR (aOR): 0.82, 95% CI 0.78-0.86 and aOR: 0.64, 95% CI 0.60-0.67, respectively); treatment was more likely to be undertaken (aOR: 1.56, 95% CI 1.49-1.63) and patients were more likely to be admitted to the hospital (aOR: 1.32, 95% CI 1.24-1.41) at night. Patterns in management during out-of-office hours were comparable between the different hospitals, with variability remaining. CONCLUSIONS Children visiting during the night are relatively more seriously ill, highlighting the need to keep improving emergency care on a 24-hour-a-day basis. Further research is needed to explain the differences in management during the night and how these differences affect patient outcomes.
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Affiliation(s)
- Gina Schinkelshoek
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Dorine M Borensztajn
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Joany M Zachariasse
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Ian K Maconochie
- Department of Paediatric Accident and Emergency, Imperial College Healthcare NHS Trust, London, UK
| | - Claudio F Alves
- Department of Paediatrics, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Paulo Freitas
- Intensive Care Unit, Professor Doutor Fernando Fonseca Hospital, Amadora, Lisboa, Portugal
| | - Frank J Smit
- Department of Paediatrics, Maasstad Hospital, Rotterdam, Zuid-Holland, The Netherlands
| | - Johan van der Lei
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Susanne Greber-Platzer
- Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria
| | - Henriëtte A Moll
- Department of General Paediatrics, Erasmus MC Sophia Children Hospital, Rotterdam, Zuid-Holland, The Netherlands
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McDaniel CE, Jeske M, Sampayo EM, Liu P, Walls TA, Kaiser SV. Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study. J Hosp Med 2020; 15:35-41. [PMID: 31532746 DOI: 10.12788/jhm.3296] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally. OBJECTIVE The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals. METHODS We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation. RESULTS Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications). CONCLUSIONS Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.
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Affiliation(s)
- Corrie E McDaniel
- Department of Pediatrics, University of Washington, Seattle, Washington
| | - Melanie Jeske
- Department of Social and Behavioral Sciences, University of California, San Francisco, California
| | - Esther M Sampayo
- Section of Emergency Medicine, Baylor College of Medicine, Houston, Texas
| | - Peony Liu
- Kaiser Permanente Southern California Medical Group, San Diego, California
| | - Theresa A Walls
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
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Tideman S, Santillana M, Bickel J, Reis B. Internet search query data improve forecasts of daily emergency department volume. J Am Med Inform Assoc 2019; 26:1574-1583. [PMID: 31730701 PMCID: PMC7647136 DOI: 10.1093/jamia/ocz154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 07/25/2019] [Accepted: 08/06/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Emergency departments (EDs) are increasingly overcrowded. Forecasting patient visit volume is challenging. Reliable and accurate forecasting strategies may help improve resource allocation and mitigate the effects of overcrowding. Patterns related to weather, day of the week, season, and holidays have been previously used to forecast ED visits. Internet search activity has proven useful for predicting disease trends and offers a new opportunity to improve ED visit forecasting. This study tests whether Google search data and relevant statistical methods can improve the accuracy of ED volume forecasting compared with traditional data sources. MATERIALS AND METHODS Seven years of historical daily ED arrivals were collected from Boston Children's Hospital. We used data from the public school calendar, National Oceanic and Atmospheric Administration, and Google Trends. Multiple linear models using LASSO (least absolute shrinkage and selection operator) for variable selection were created. The models were trained on 5 years of data and out-of-sample accuracy was judged using multiple error metrics on the final 2 years. RESULTS All data sources added complementary predictive power. Our baseline day-of-the-week model recorded average percent errors of 10.99%. Autoregressive terms, calendar and weather data reduced errors to 7.71%. Search volume data reduced errors to 7.58% theoretically preventing 4 improperly staffed days. DISCUSSION The predictive power provided by the search volume data may stem from the ability to capture population-level interaction with events, such as winter storms and infectious diseases, that traditional data sources alone miss. CONCLUSIONS This study demonstrates that search volume data can meaningfully improve forecasting of ED visit volume and could help improve quality and reduce cost.
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Affiliation(s)
- Sam Tideman
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Mauricio Santillana
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan Bickel
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Ben Reis
- Computational Health Informatics Program, Boston Children’s Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
- Predictive Medicine Group, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Trends in United States emergency department visits and associated charges from 2010 to 2016. Am J Emerg Med 2019; 38:1576-1581. [PMID: 31519380 DOI: 10.1016/j.ajem.2019.158423] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/30/2019] [Accepted: 09/03/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Demographic shifts and care delivery system evolution affect the number of Emergency Department (ED) visits and associated costs. Recent aggregate trends in ED visit rates and charges between 2010 and 2016 have not been evaluated. METHODS Data from the National Emergency Department Sample, comprising approximately 30 million annual patient visits, were used to estimate the ED visit rate and charges per visit from 2010 to 2016. ED visits were grouped into 144 mutually exclusive clinical categories. Visit rates, compound annual growth rates (CAGRs), and per visit charges were estimated. RESULTS From 2010 to 2016, the number of ED visits increased from 128.97 million to 144.82 million; the cumulative growth was 12.29% and the CAGR was 1.95%, while the population grew at a CAGR of 0.73%. Expressed as a population rate, ED visits per 1000 persons increased from 416.92 in 2010 to 448.19 in 2016 (p value <0.001). The mean charges per visit increased from $2061 (standard deviation $2962) in 2010 to $3516 (standard deviation $2962) in 2016; the CAGR was 9.31% (p value <0.001). Of 144 clinical categories, 140 categories had a CAGR for mean charges per visit of at least 5%. CONCLUSION The rate of ED visits per 1000 persons and the mean charge per ED visit increased significantly between 2010 and 2016. Mean charges increased for both high- and low-acuity clinical categories. Visits for the 5 most common clinical categories comprise about 30% of ED visits, and may represent focus areas for increasing the value of ED care.
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Durbin A, Balogh R, Lin E, Wilton AS, Selick A, Dobranowski KM, Lunsky Y. Repeat Emergency Department Visits for Individuals With Intellectual and Developmental Disabilities and Psychiatric Disorders. AMERICAN JOURNAL ON INTELLECTUAL AND DEVELOPMENTAL DISABILITIES 2019; 124:206-219. [PMID: 31026200 DOI: 10.1352/1944-7558-124.3.206] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Although individuals with intellectual and developmental disabilities (IDD) and psychiatric concerns are more likely than others to visit hospital emergency departments (EDs), the frequency of their returns to the ED within a short time is unknown. In this population-based study we examined the likelihood of this group returning to the ED within 30 days of discharge and described these visits for individuals with IDD + psychiatric disorders (n = 3,275), and persons with IDD only (n = 1,944) compared to persons with psychiatric disorders only (n = 41,532). Individuals with IDD + psychiatric disorders, and individuals with IDD alone were more likely to make 30-day repeat ED visits. Improving hospital care and postdischarge community linkages may reduce 30-day returns to the ED among adults with IDD.
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Affiliation(s)
- Anna Durbin
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Robert Balogh
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Elizabeth Lin
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Andrew S Wilton
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Avra Selick
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Kristin M Dobranowski
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Yona Lunsky
- Anna Durbin, St. Michael's Hospital, Toronto, ON, Canada; Robert Balogh, University of Ontario Institute of Technology, Oshawa, ON, Canada; Elizabeth Lin, Centre for Addiction and Mental Health, Toronto, ON, Canada; Andrew S. Wilton, Institute for Clinical Evaluative Sciences, Toronto, ON, Canada; Avra Selick, Centre for Addiction and Mental Health, Toronto, ON, Canada; Kristin M. Dobranowski, University of Ontario Institute of Technology, Oshawa, ON, Canada; and Yona Lunsky, Centre for Addiction and Mental Health, Toronto, ON, Canada
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Zook HG, Payne NR, Puumala SE, Burgess K, Kharbanda AB. Racial/Ethnic Variation in Emergency Department Care for Children With Asthma. Pediatr Emerg Care 2019; 35:209-215. [PMID: 28926508 PMCID: PMC5857394 DOI: 10.1097/pec.0000000000001282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To assess the variation between racial/ethnic groups in emergency department (ED) treatment of asthma for pediatric patients. METHODS This study was a cross-sectional analysis of pediatric (2-18 years) asthma visits among 6 EDs in the Upper Midwest between June 2011 and May 2012. We used mixed-effects logistic regression to assess the odds of receiving steroids, radiology tests, and returning to the ED within 30 days. We conducted a subanalysis of asthma visits where patients received at least 1 albuterol treatment in the ED. RESULTS The sample included 2909 asthma visits by 1755 patients who were discharged home from the ED. After adjusting for demographics, insurance type, and triage score, African American (adjusted odds ratio [aOR], 1.78; 95% confidence interval [CI], 1.40-2.26) and Hispanic (aOR, 1.64; 95% CI, 1.22-2.22) patients had higher odds of receiving steroids compared with whites. African Americans (aOR, 0.58; 95% CI, 0.46-0.74) also had lower odds of radiological testing compared with whites. Asians had the lowest odds of 30-day ED revisits (aOR, 0.26; 95% CI, 0.08-0.84), with no other significant differences detected between racial/ethnic groups. Subgroup analyses of asthma patients who received albuterol revealed similar results, with American Indians showing lower odds of radiological testing as well (aOR, 0.47; 95% CI, 0.22-1.01). CONCLUSIONS In this study, children from racial/ethnic minority groups had higher odds of steroid administration and lower odds of radiological testing compared with white children. The underlying reasons for these differences are likely multifactorial, including varying levels of disease severity, health literacy, and access to care.
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Affiliation(s)
- Heather G. Zook
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Evaluation, Professional Data Analysts, Inc., 219 Main Street SE, Suite 302, Minneapolis, MN 55414
| | - Nathaniel R. Payne
- Department of Research and Sponsored Programs, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
- Department of Quality and Safety, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
| | - Susan E. Puumala
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Pediatrics, Sanford School of Medicine at the University of South Dakota, 1400 W 22nd Street, Sioux Falls, SD 57105
| | - Katherine Burgess
- Center for Health Outcomes and Prevention Research, Sanford Research, 2301 E 60th Street North, Sioux Falls, SD 57104
- Department of Epidemiology, Colorado School of Public Health at the University of Colorado at Denver, 13001 East 17 Place, Aurora, CO 80045
| | - Anupam B. Kharbanda
- Department of Emergency Medicine, Children’s Hospitals and Clinics of Minnesota, 2525 Chicago Avenue South, Minneapolis, MN 55404
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Epidemiology and Resource Utilization of Simple Febrile Seizure-associated Hospitalizations in the United States, 2003-2012. J Neurosurg Anesthesiol 2019; 31:144-150. [PMID: 30767940 DOI: 10.1097/ana.0000000000000546] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Simple febrile seizure (SFS) affects 2% to 4% of children under 6 years of age. The purpose of this study is to examine the epidemiologic patterns and resource utilization of SFS-associated hospitalizations in children aged younger than 6 years of age in the United States. MATERIALS AND METHODS This study is a serial, retrospective analysis of the Healthcare Cost and Utilization Project Kids' Inpatient Databases for the years 2003, 2006, 2009, and 2012. SFS-associated hospitalizations were identified based on International Classification of Diseases, Ninth Revision, Clinical Modification, diagnosis code 780.31. We calculated the proportion of hospitalizations in pediatric patients under 6 years of age due to SFS and all other nonbirth causes, the rate of SFS-associated hospitalizations per 100,000 population, the mean length of stay and inflation-adjusted hospital costs of SFS-associated hospitalizations, as well as patient demographics and hospital characteristics. RESULTS From 2003 to 2012, the weighted proportion of hospitalizations due to SFS declined from 0.83% to 0.41% (P<0.01) and the annual rate of SFS-associated hospitalizations per 100,000 population decreased from 48.0 to 18.7 (P<0.01). However, use of computed tomography, electroencephalogram, and lumbar puncture in SFS-associated hospitalizations decreased significantly (all P<0.001), but the utilization rate of magnetic resonance imaging remained stable (P=0.53). The mean length of stay for SFS-associated hospitalizations decreased from 2.03 days in 2003 to 1.74 days in 2012, and the mean hospital costs (exclusive of professional payment) decreased from $3830 in 2003 to $3223 in 2012 (both P<0.001). CONCLUSIONS SFS-associated hospitalizations and resource utilization in children under 6 years of age have decreased markedly in the United States, probably due to improved clinical adherence to the practice parameters set forth by the American Academy of Pediatrics for managing patients with SFS.
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Abstract
OBJECTIVES The aim of this study was to describe the resource utilization for children with common pediatric conditions treated in academic and nonacademic emergency departments (EDs). METHODS We performed a retrospective, cross-sectional descriptive study using the National Hospital Ambulatory Medical Care Survey Data from 1995 to 2010 including children less than 18 years old with a diagnosis of asthma, bronchiolitis, croup, gastroenteritis, fever, febrile seizure, or afebrile seizure. Academic EDs (A-ED) were those with greater than 25% of patients seen by a trainee. For each condition, we reported the proportion of testing, medications, and disposition between A-ED and nonacademic EDs (NA-ED). RESULTS From 1995 to 2010, approximately 450,000,000 estimated pediatric visits are represented by the survey based on 122,811 actual visits. For most common conditions, testing and disposition were comparable; however, some variation was noted. Among patients with bronchiolitis, a higher proportion of patients was admitted and had radiographs in NA-EDs (18% vs 10% and 56% vs 45%, respectively). For children with croup, radiographs were performed more often at NA-EDs (27% vs 6%). Among those with febrile seizures, more lumbar punctures were performed in NA-EDs (14% vs 0%). In children with afebrile seizures, more head computed tomography scans were obtained at NA-EDs (34% vs 21%). CONCLUSION Among pediatric patients with croup, bronchiolitis, and febrile and afebrile seizure, higher resource utilization and admissions were observed in NA-EDs. These preliminary findings from a national survey require a more detailed investigation into the variation in care between A-ED and NA-ED settings.
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Sills MR, Macy ML, Kocher KE, Sabbatini AK. Return Visit Admissions May Not Indicate Quality of Emergency Department Care for Children. Acad Emerg Med 2018; 25:283-292. [PMID: 28960666 DOI: 10.1111/acem.13324] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 08/26/2017] [Accepted: 09/04/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to test the hypothesis that in-hospital outcomes are worse among children admitted during a return ED visit than among those admitted during an index ED visit. METHODS This was a retrospective analysis of ED visits by children age 0 to 17 to hospitals in Florida and New York in 2013. Children hospitalized during an ED return visit within 7 days were classified as "ED return admissions" (discharged at ED index visit and admitted at return visit) or "readmissions" (admission at both ED index and return visits). In-hospital outcomes for ED return admissions and readmissions were compared to "index admissions without return admission" (admitted at ED index visit without 7-day return visit admission). RESULTS Among 1,886,053 index ED visits to 321 hospitals, 75,437 were index admissions without return admission, 7,561 were ED return admissions, and 1,333 were readmissions. ED return admissions had lower intensive care unit admission rates (11.0% vs. 13.6%; adjusted odds ratio = 0.78; 95% confidence interval [CI] = 0.71 to 0.85), longer length of stay (3.51 days vs. 3.38 days; difference = 0.13 days; incidence rate ratio = 1.04; 95% CI = 1.02 to 1.07), but no difference in mean hospital costs (($7,138 vs. $7,331; difference = -$193; 95% CI = -$479 to $93) compared to index admissions without return admission. CONCLUSIONS Compared with children who experienced index admissions without return admission, children who are initially discharged from the ED who then have a return visit admission had lower severity and similar cost, suggesting that ED return visit admissions do not involve worse outcomes than do index admissions.
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Affiliation(s)
- Marion R. Sills
- Departments of Pediatrics and Emergency Medicine and the Adult and Child Consortium for Outcomes Research and Delivery Science University of Colorado School of Medicine and Children's Hospital Colorado (MRS) AuroraCO
| | - Michelle L. Macy
- Department of Pediatrics University of Michigan Ann Arbor MI
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Child Health Evaluation and Research University of Michigan Ann Arbor MI
| | - Keith E. Kocher
- Department of Emergency Medicine University of Michigan Ann Arbor MI
- Institute for Healthcare Policy and Innovation University of Michigan Ann Arbor MI
| | - Amber K. Sabbatini
- Division of Emergency Medicine University of Washington Harborview Medical Center Seattle WA
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Johnson MD, Nkoy FL, Sheng X, Greene T, Stone BL, Garvin J. Direct concurrent comparison of multiple pediatric acute asthma scoring instruments. J Asthma 2017; 54:741-753. [PMID: 27831833 PMCID: PMC5425314 DOI: 10.1080/02770903.2016.1258081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/02/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Appropriate delivery of Emergency Department (ED) treatment to children with acute asthma requires clinician assessment of acute asthma severity. Various clinical scoring instruments exist to standardize assessment of acute asthma severity in the ED, but their selection remains arbitrary due to few published direct comparisons of their properties. Our objective was to test the feasibility of directly comparing properties of multiple scoring instruments in a pediatric ED. METHODS Using a novel approach supported by a composite data collection form, clinicians categorized elements of five scoring instruments before and after initial treatment for 48 patients 2-18 years of age with acute asthma seen at the ED of a tertiary care pediatric hospital ED from August to December 2014. Scoring instruments were compared for inter-rater reliability between clinician types and their ability to predict hospitalization. RESULTS Inter-rater reliability between clinician types was not different between instruments at any point and was lower (weighted kappa range 0.21-0.55) than values reported elsewhere. Predictive ability of most instruments for hospitalization was higher after treatment than before treatment (p < 0.05) and may vary between instruments after treatment (p = 0.054). CONCLUSIONS We demonstrate the feasibility of comparing multiple clinical scoring instruments simultaneously in ED clinical practice. Scoring instruments had higher predictive ability for hospitalization after treatment than before treatment and may differ in their predictive ability after initial treatment. Definitive conclusions about the best instrument or meaningful comparison between instruments will require a study with a larger sample size.
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Affiliation(s)
- Michael D. Johnson
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Flory L. Nkoy
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
| | - Xiaoming Sheng
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Tom Greene
- Department of Population Health Sciences, University of Utah School
of Medicine, 295 Chipeta Way, Salt Lake City, UT 84108, USA
| | - Bryan L. Stone
- Department of Pediatrics, University of Utah School of Medicine, 100
N Mario Capecchi Drive, Salt Lake City, UT 84113, USA
| | - Jennifer Garvin
- Department of Biomedical Informatics, University of Utah School of
Medicine, Suite 140, 421 Wakara Way, Salt Lake City, UT 84108, USA
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Improving Timeliness of β-Agonist and Corticosteroid Administration in Patients With Acute Wheezing. Pediatr Emerg Care 2017; 33:635-642. [PMID: 28816890 DOI: 10.1097/pec.0000000000001249] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Timely delivery of β-agonists and steroids to patients with acute recurrent wheezing is a key component of the National Heart, Lung, and Blood Institute recommended emergency department (ED) asthma care. We conducted an ED improvement initiative to standardize asthma care and improve time to treatments. METHODS Our multidisciplinary team identified key contributing factors to timeliness, developed key driver diagrams, implemented and refined a management pathway, designed and executed rapid cycle improvements, and implemented interventions. A time series design was used to analyze outcomes with baseline data and continuous monitoring during active intervention steps. The primary outcomes analyzed were the times to first β-agonist and steroid administration. Secondary outcomes included admission rate, ED length of stay, and ED revisits. RESULTS Assignment of the Pediatric Asthma Score, our initial pathway step, occurred in most patients within the first several months. Time to first β-agonist administration decreased from the baseline mean of 76 minutes to 27 minutes. Time to steroid administration decreased from the baseline mean of 108 minutes to 49 minutes. Mean monthly admission rate remained at 22% with no special cause variation identified. The ED revisit rate was not negatively impacted and, in most months, was 0%. CONCLUSIONS By standardizing asthma care in our ED and redesigning care delivery processes, care variation decreased and significant improvements in timeliness of β-agonist and steroid administration occurred.
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Tavarez MM, Ayers B, Jeong JH, Coombs CM, Thompson A, Hickey RW. Practice Variation and Effects of E-mail-only Performance Feedback on Resource Use in the Emergency Department. Acad Emerg Med 2017; 24:948-956. [PMID: 28470786 DOI: 10.1111/acem.13211] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/07/2017] [Accepted: 04/20/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Higher resource utilization in the management of pediatric patients with undifferentiated vomiting and/or diarrhea does not correlate consistently with improved outcomes or quality of care. Performance feedback has been shown to change physician practice behavior and may be a mechanism to minimize practice variation. We aimed to evaluate the effects of e-mail-only, provider-level performance feedback on the ordering and admission practice variation of pediatric emergency physicians for patients presenting with undifferentiated vomiting and/or diarrhea. METHODS We conducted a prospective, quality improvement intervention and collected data over 3 consecutive fiscal years. The setting was a single, tertiary care pediatric emergency department. We collected admission and ordering practices data on 19 physicians during baseline, intervention, and postintervention periods. We provided physicians with quarterly e-mail-based performance reports during the intervention phase. We measured admission rate and created four categories for ordering practices: no orders, laboratory orders, pharmacy orders, and radiology orders. RESULTS There was wide (two- to threefold) practice variation among physicians. Admission rates ranged from 15% to 30%, laboratory orders from 19% to 43%, pharmacy orders from 29% to 57%, and radiology orders from 11% to 30%. There was no statistically significant difference in the proportion of patients admitted or with radiology or pharmacy orders placed between preintervention, intervention, or postintervention periods (p = 0.58, p = 0.19, and p = 0.75, respectively). There was a significant but very small decrease in laboratory orders between the preintervention and postintervention periods. CONCLUSIONS Performance feedback provided only via e-mail to pediatric emergency physicians on a quarterly basis does not seem to significantly impact management practices for patients with undifferentiated vomiting and/or diarrhea.
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Affiliation(s)
- Melissa M. Tavarez
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Brandon Ayers
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
| | - Jong H. Jeong
- Department of Biostatistics; Graduate School of Public Health; University of Pittsburgh; Pittsburgh PA
| | - Carmen M. Coombs
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Ann Thompson
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
| | - Robert W. Hickey
- The Children's Hospital of Pittsburgh of UPMC; Pittsburgh PA
- The University of Pittsburgh; School of Medicine; Pittsburgh PA
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Comparing Practice Patterns Between Pediatric and General Emergency Medicine Physicians: A Scoping Review. Pediatr Emerg Care 2017; 33:278-286. [PMID: 28355170 DOI: 10.1097/pec.0000000000000557] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Acutely ill infants and children presenting to the emergency department are treated by either physicians with pediatric emergency medicine (PEM) training or physicians without PEM training, a good proportion of which are general emergency medicine-trained physicians (GEDPs). This scoping review identified published literature comparing the care provided to infants and children (≤21 years of age) by PEM-trained physicians to that provided by GEDPs. METHODS The search was conducted in 2 main steps as follows: (1) initial literature search to identify available literature with evolving feedback from the group while simultaneously deciding search concepts as well as inclusion and exclusion criteria and (2) modification of search concepts and conduction of search using finalized concepts as well as review and selection of articles for final analysis using set inclusion criteria. Each study was independently assessed by 2 reviewers for eligibility and quality. Data were independently abstracted by reviewers, and authors were contacted for missing data. RESULTS Our search yielded 3137 titles and abstracts. Twenty articles reporting 19 studies were included in the final analysis. The studies were grouped under type of care, diagnostic studies, medication administration, and process of care. The studies addressed differences in the management of fever, croup, bronchiolitis, asthma, urticaria, febrile seizures, and diabetic ketoacidosis. CONCLUSIONS This review highlights the lack of robust studies and heterogeneity of literature comparing practice patterns of PEM-trained physicians with GEDPs. We have outlined a systematic approach to reviewing a body of literature for topics that lack clear terms of comparison across studies.
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Walls TA, Hughes NT, Mullan PC, Chamberlain JM, Brown K. Improving Pediatric Asthma Outcomes in a Community Emergency Department. Pediatrics 2017; 139:peds.2016-0088. [PMID: 27940506 DOI: 10.1542/peds.2016-0088] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/01/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Asthma triggers >775 000 emergency department (ED) visits for children each year. Approximately 80% of these visits occur in community EDs. We performed this study to measure effects of partnership with a community ED on pediatric asthma care. METHODS For this quality improvement initiative, we implemented an evidence-based pediatric asthma guideline in a community ED. We included patients whose clinical impression in the medical decision section of the electronic health record contained the words asthma, bronchospasm, or wheezing. We reviewed charts of included patients 12 months before guideline implementation (August 2012-July 2013) and 19 months after guideline implementation (August 2013-February 2015). Process measures included the proportion of children who had an asthma score recorded, the proportion who received steroids, and time to steroid administration. The outcome measure was the proportion of children who needed transfer for additional care. RESULTS In total, 724 patients were included, 289 during the baseline period and 435 after guideline implementation. Overall, 64% of patients were assigned an asthma score after guideline implementation. During the baseline period, 60% of patients received steroids during their ED visit, compared with 76% after guideline implementation (odds ratio 2.2; 95% confidence interval, 1.6-3.0). After guideline implementation, the mean time to steroids decreased significantly, from 196 to 105 minutes (P < .001). Significantly fewer patients needed transfer after guideline implementation (10% compared with 14% during the baseline period) (odds ratio 0.63; 95% confidence interval, 0.40-0.99). CONCLUSIONS Our study shows that partnership between a pediatric tertiary care center and a community ED is feasible and can improve pediatric asthma care.
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Affiliation(s)
- Theresa A Walls
- Children's National Health Systems, Washington, District of Columbia;
| | - Naomi T Hughes
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Paul C Mullan
- Children's Hospital of the King's Daughters, Norfolk, Virginia
| | | | - Kathleen Brown
- Children's National Health Systems, Washington, District of Columbia
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Clinical Practice Guideline for the Treatment of Pediatric Acute Gastroenteritis in the Outpatient Setting. J Pediatr Health Care 2016; 30:610-616. [PMID: 27268427 DOI: 10.1016/j.pedhc.2016.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 04/08/2016] [Accepted: 04/21/2016] [Indexed: 11/20/2022]
Abstract
Acute gastroenteritis (AGE) is a common illness in childhood that usually can be treated in the outpatient setting. Inaccurate assessment or delayed treatment of AGE can lead to an increased risk for invasive interventions. A literature search was conducted using PubMed, CINAHL Plus, the Cochrane Library, and Embase. Results of the query were refined to narrow the focus of relevant studies for the provider caring for dehydrated children in the outpatient setting. Use of clinical dehydration scales to assess the level of dehydration and early initiation of oral rehydration therapy promote optimal patient outcomes. Oral rehydration therapy remains the best means of rehydrating, and ondansetron is a safe and effective adjunct to help children with persistent vomiting. The purpose of this practice guideline is to identify best practices for AGE in children older than 6 months with symptoms for less than 7 days who are being cared for in the outpatient setting.
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Ondansetron for pediatric concussion; a pilot study for a randomized controlled trial. CAN J EMERG MED 2016; 19:338-346. [DOI: 10.1017/cem.2016.369] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
AbstractObjectivesAssess the feasibility of a study evaluating one dose of oral ondansetron to decrease post-concussion symptoms at one week and one month following concussion in children aged 8 to 17 years old.MethodThis was a pilot study for a randomized, triple-blind controlled trial of one dose of either ondansetron or placebo performed in a tertiary care pediatric emergency department. Participants were children aged 8 to 17 years who sustained a concussion in the previous 24 hours and visited a single emergency department. The outcome of interest was an increase from pre-concussion baseline of at least 3 symptoms from the Post-Concussion Symptom Inventory, measured at one week and at one month following concussion. The primary outcome was to determine the proportion of children who completed the assessment at one week following the intervention. Secondary outcome was the proportion of children who completed the assessment at one month following the intervention. All children, care givers, and those assessing the outcomes were blinded to the group assignment.ResultsOf the 218 children presenting with a concussion during the study period, we screened 108 and found 36/108 (33%) eligible to participate and 16/108 (14.8%) agreed to participate. All enrolled patients were compliant with the intervention and follow-up.ConclusionIn our study population, approximately one-third of the screened concussion patients were eligible to participate and approximately one half of those eligible agreed to participate. Our study found that most enrolled patients preferred electronic follow-up; the noncompliance rate was minimal.
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Essentials of PEM Fellowship: Part 5: Scholarship Prepares Fellows to Lead as Pediatric Emergency Specialists. Pediatr Emerg Care 2016; 32:645-7. [PMID: 27585128 DOI: 10.1097/pec.0000000000000896] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this article was to discuss the current landscape in pediatric emergency medicine fellowship training for scholarship training and provide an overview of the resources and general strategies required to prepare fellows for their careers. OVERVIEW This article is the fifth in a 7-part series that aims to comprehensively describe the current state and future directions of pediatric emergency medicine fellowship training from the essential requirements to considerations for successfully administering and managing a program to the careers that may be anticipated upon program completion. This article focuses on scholarship training.
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Mueller EL, Hall M, Shah SS, August KJ, Radhi MA, Macy ML. Characteristics of Children With Cancer Discharged or Admitted From the Emergency Department. Pediatr Blood Cancer 2016; 63:853-8. [PMID: 26713542 DOI: 10.1002/pbc.25872] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 11/20/2015] [Accepted: 11/21/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Emergency department (ED) utilization by children with cancer is poorly understood. Among children with cancer, we explored reasons for ED visits and factors associated with admission within U.S. children's hospitals. METHODS A retrospective study of the 2011-2013 Pediatric Health Information System (PHIS) was conducted. Eligible ED visits included those within 365 days from the first inpatient encounter with an International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) code for cancer. Patient characteristics and reasons for ED visits were assessed. Factors associated with admission from the ED were examined with multivariable regression. RESULTS There were 26,770 ED visits by 17,943 children with cancer at 39 children's hospitals during the study period. Half of children with cancer visited the ED within 1 year after their first cancer hospitalization in PHIS. Fifty-six percent of ED visits resulted in admission. Fever or neutropenia accounted for the largest proportion of reasons for visits (34.6%). Risk factors for admission were as follows: "Other" race/ethnicity as compared to white, non-Hispanic (odds ratio [OR] = 1.4, 95% confidence interval [CI] 1.2-1.6), history of transplant (OR = 1.7, 95% CI 1.4-2.1), and ED visits reasons including neutropenia (OR = 43.4, 95% CI 36.0-52.3), blood stream infection (OR = 3.3, 95% CI 2.8-3.9), pancytopenia (OR = 28.8, 95% CI 18.1-45.9), dehydration (OR = 2.3, 95% CI 1.9-2.9), or pneumonia (OR = 3.8, 95% CI 2.8-5.1). CONCLUSIONS Children with cancer have high ED usage within 1 year after their first cancer hospitalization. Age, demographic factors, and reasons for ED visits significantly impacted admission from the ED. Further research should focus on ED utilization among children with cancer.
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Affiliation(s)
- Emily L Mueller
- Section of Pediatric Hematology Oncology, Department of Pediatrics, Indiana University, Indianapolis, Indiana.,Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Samir S Shah
- Division of Hospital Medicine, Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Keith J August
- Section of Pediatric Hematology/Oncology/Stem Cell Transplantation, University of Missouri, Kansas City, Missouri
| | - Mohamed A Radhi
- Section of Pediatric Hematology/Oncology/Stem Cell Transplantation, University of Missouri, Kansas City, Missouri
| | - Michelle L Macy
- Child, Health Evaluation and Research (CHEAR) Unit, Division of General Pediatrics, Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, Michigan.,Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan
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Michelson KA, Monuteaux MC, Neuman MI. Variation and Trends in Anaphylaxis Care in United States Children's Hospitals. Acad Emerg Med 2016; 23:623-7. [PMID: 26833535 DOI: 10.1111/acem.12922] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 12/13/2015] [Accepted: 12/18/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We sought to determine the extent of variation in treatment of children with anaphylaxis. METHODS We identified children 1 month to 18 years of age presenting with a primary diagnosis of anaphylaxis to one of the 35 pediatric hospitals included in the Pediatric Health Information System between January 1, 2009, and September 30, 2013. We evaluated the variation in use of β2 agonists, glucocorticoids, histamine-1 (H1) antagonists, histamine-2 (H2) antagonists, inhaled epinephrine, intravenous fluids, and oxygen. We assessed whether variation exists in the rates of hospitalization and 3-day emergency department (ED) revisits and whether a temporal trend exists in the ED visit rate for anaphylaxis. RESULTS Among 10,351 children with anaphylaxis, the hospital-level median use of common anaphylaxis therapies varied for β2 agonists (22%, interquartile range [IQR] = 16%-26%), glucocorticoids (71%, IQR = 65%-76%), H1 blockers (60%, IQR = 57%-65%), H2 blockers (53%, IQR = 36%-64%), inhaled epinephrine (2.2%, IQR = 1.3%-3.5%), intravenous fluids (26%, IQR = 13%-41%), and oxygen (2.6%, IQR = 0.8%-4.1%). Hospitalization rates ranged from 12% to 95%, with a median rate of 41%. Anaphylaxis diagnoses rose from 5.7 to 11.7 patients per 10,000 ED visits between 2009 and 2013 (p < 0.001 for trend). CONCLUSIONS There is substantial variability in the use of common therapies and hospitalization rates for children cared for in U.S. children's hospitals. Additionally, ED visits for children with anaphylaxis are increasing at U.S. children's hospitals. These findings highlight the need for research defining optimal care for anaphylaxis.
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Affiliation(s)
| | | | - Mark I. Neuman
- Division of Emergency Medicine; Boston Children's Hospital; Boston MA
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Borland ML, Shepherd M. Quality in paediatric emergency medicine: Measurement and reporting. J Paediatr Child Health 2016; 52:131-6. [PMID: 27062615 DOI: 10.1111/jpc.13077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/12/2015] [Accepted: 07/30/2015] [Indexed: 11/29/2022]
Abstract
There is a clear demand for quality in the delivery of health care around the world; paediatric emergency medicine is no exception to this movement. It has been identified that gaps exist in the quality of acute care provided to children. Regulatory bodies in Australia and New Zealand are moving to mandate the implementation of quality targets and measures. Within the paediatric emergency department (ED), there is a lack of research into paediatric specific indicators. The existing literature regarding paediatric acute care quality measures has been recently summarised, and expert consensus has now been reported. It is clear that there is much work to be performed to generalise this work to ED. We review suggestions from the current literature relating to feasible indicators within the paediatric acute care setting. We propose options to develop a quality 'scorecard' that could be used to assist Australian and New Zealand EDs with quality measurement and benchmarking for their paediatric patients.
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Affiliation(s)
- Meredith L Borland
- Emergency Department, Princess Margaret Hospital, Perth, Western Australia, Australia.,Schools of Paediatric and Child Health, Western Australia, Australia.,Primary Aboriginal and Rural Healthcare, University of Western Australia, Perth, Western Australia, Australia
| | - Mike Shepherd
- Children's Emergency Department, Starship Children's Hospital.,Auckland District Health Board.,Department of Paediatrics, University of Auckland, Auckland, New Zealand
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Bekmezian A, Fee C, Weber E. Clinical pathway improves pediatrics asthma management in the emergency department and reduces admissions. J Asthma 2015; 52:806-14. [PMID: 25985707 PMCID: PMC4669067 DOI: 10.3109/02770903.2015.1019086] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Poor adherence to the National Institute of Health (NIH) Asthma Guidelines may result in unnecessary admissions for children presenting to the emergency department (ED) with exacerbations. We determine the effect of implementing an evidence-based ED clinical pathway on corticosteroid and bronchodilator administration and imaging utilization, and the subsequent effect on hospital admissions in a US ED. METHODS A prospective, interventional study of pediatric (≤21 years) visits to an academic ED between 2011 and 2013 with moderate-severe asthma exacerbations has been conducted. A multidisciplinary team designed a one-page clinical pathway based on the NIH Guidelines. Nurses, respiratory therapists and physicians attended educational sessions prior to the pathway implementation. By adjusting for demographics, acuity and ED volume, we compared timing and appropriateness of corticosteroid and bronchodilator administration, and chest radiograph (CXR) utilization with historical controls from 2006 to 2011. Subsequent hospital admission rates were also compared. RESULTS A total of 379 post-intervention visits were compared with 870 controls. Corticosteroids were more likely to be administered during post-intervention visits (96% vs. 78%, adjusted OR 6.35; 95% CI 3.17-12.73). Post-intervention, median time to corticosteroid administration was 45 min faster (RR 0.74; 95% CI 0.67-0.81) and more patients received corticosteroids within 1 h of arrival (45% vs. 18%, OR 3.5; 95% CI 2.50-4.90). More patients received > 1 bronchodilator dose within 1 h (36% vs. 24%, OR 1.65; 95% CI 1.23-2.21) and fewer received CXRs (27% vs. 42%, OR 0.7; 95% CI 0.52-0.94). There were fewer admissions post-intervention (13% vs. 21%, OR 0.53; 95% CI 0.37-0.76). CONCLUSION A clinical pathway is associated with improved adherence to NIH Guidelines and, subsequently, fewer hospital admissions for pediatric ED patients with asthma exacerbations.
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Affiliation(s)
- Arpi Bekmezian
- Department of Pediatrics, University of California, San Francisco
| | - Christopher Fee
- Department of Emergency Medicine, University of California, San Francisco
| | - Ellen Weber
- Department of Emergency Medicine, University of California, San Francisco
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Uspal NG, Klein EJ, Tieder JS, Oron AP, Simon TD. Variation in the use of procedural sedation for incision and drainage of skin and soft tissue infection in pediatric emergency departments. Hosp Pediatr 2015; 5:185-92. [PMID: 25832973 DOI: 10.1542/hpeds.2014-0115] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Little is known about procedural sedation use for anxiety and pain associated with skin and soft tissue infections (SSTIs) requiring incision and drainage (I&D). Our objectives were therefore (1) to characterize the use of procedural sedation use for SSTI I&D procedures in pediatric emergency departments (EDs), (2) to compare the frequency of procedural sedation for I&D across hospitals, and (3) to determine factors associated with use of procedural sedation for I&D. METHODS We performed a retrospective cohort study of pediatric EDs contributing to the Pediatric Health Information Systems database in 2010. Cases were identified by primary International Classification of Diseases, 9th revision, Clinical Modification procedure codes for I&D. We used descriptive statistics to describe procedural sedation use across hospitals and logistic generalized linear mixed models to identify factors associated with use of procedural sedation. RESULTS There were 6322 I&D procedures, and procedural sedation was used in 24% of cases. Hospital-level use of procedural sedation varied widely, with a range of 2% to 94% (median 17%). Procedural sedation use was positively associated with sensitive body site, female gender, and employer-based insurance, and negatively associated with African American race and increasing age. Estimates of hospital-level use of procedural sedation for a referent case eliminating demographic differences exhibit similar variability with a range of 5% to 97% (median 34%). CONCLUSIONS Use of procedural sedation for SSTI I&D varies widely across pediatric EDs, and the majority of variation is independent of demographic differences. Additional work is needed to understand decision-making and to standardize delivery of procedural sedation in children requiring I&D.
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Affiliation(s)
- Neil G Uspal
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Eileen J Klein
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Joel S Tieder
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Assaf P Oron
- Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Tamara D Simon
- Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington; and Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Jain S, Frank G, McCormick K, Wu B, Johnson BA. Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency. Pediatrics 2015; 136:e670-9. [PMID: 26260722 DOI: 10.1542/peds.2014-2363] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency. METHODS We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed. RESULTS In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P < .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P < .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P < .001 and P < .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change. CONCLUSIONS Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.
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Affiliation(s)
- Shabnam Jain
- Department of Pediatrics and Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Gary Frank
- Children's Healthcare of Atlanta, Atlanta, Georgia; and
| | - Kelly McCormick
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Baohua Wu
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Brent A Johnson
- Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
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Freedman SB, Pasichnyk D, Black KJL, Fitzpatrick E, Gouin S, Milne A, Hartling L. Gastroenteritis Therapies in Developed Countries: Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0128754. [PMID: 26075617 PMCID: PMC4468143 DOI: 10.1371/journal.pone.0128754] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 04/09/2015] [Indexed: 01/27/2023] Open
Abstract
Context Gastroenteritis remains a leading cause of childhood morbidity. Objective Because prior reviews have focused on isolated symptoms and studies conducted in developing countries, this study focused on interventions commonly considered for use in developed countries. Intervention specific, patient-centered outcomes were selected. Data Sources MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, trial registries, grey literature, and scientific meetings. Study Selection Randomized controlled trials, conducted in developed countries, of children aged <18 years, with gastroenteritis, performed in emergency department or outpatient settings which evaluated oral rehydration therapy (ORT), antiemetics, probiotics or intravenous fluid administration rate. Data Extraction The study was conducted in accordance with the Cochrane Handbook for Systematic Reviews of Interventions and the PRISMA guidelines. Data were independently extracted by multiple investigators. Analyses employed random effects models. Results 31 trials (4,444 patients) were included. ORT: Compared with intravenous rehydration, hospitalization (RR 0.80, 95%CI 0.24, 2.71) and emergency department return visits (RR 0.86, 95%CI 0.39, 1.89) were similar. Antiemetics: Fewer children administered an antiemetic required intravenous rehydration (RR 0.40, 95%CI 0.26, 0.60) While the data could not be meta-analyzed, three studies reported that ondansetron administration does increase the frequency of diarrhea. Probiotics: No studies reported on the primary outcome, three studies evaluated hospitalization within 7 days (RR 0.87, 95%CI 0.25, 2.98). Rehydration: No difference in length of stay was identified for rapid vs. standard intravenous or nasogastric rehydration. A single study found that 5% dextrose in normal saline reduced hospitalizations compared with normal saline alone (RR 0.70, 95% CI 0.53, 0.92). Conclusions There is a paucity of patient-centered outcome evidence to support many interventions. Since ORT is a low-cost, non-invasive intervention, it should continue to be used. Routine probiotic use cannot be endorsed at this time in outpatient children with gastroenteritis. Despite some evidence that ondansetron administration increases diarrhea frequency, emergency department use leads to reductions in intravenous rehydration and hospitalization. No benefits were associated with ondansetron use following emergency department discharge.
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Affiliation(s)
- Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- * E-mail:
| | - Dion Pasichnyk
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Karen J. L. Black
- Division of Pediatric Emergency Medicine, BC Children’s Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eleanor Fitzpatrick
- IWK Health Centre, Emergency Department, Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Serge Gouin
- Section of Pediatric Emergency Medicine, Centre Hospitalier Universitaire Ste-Justine, Université de Montréal, Montréal, Quebec, Canada
| | - Andrea Milne
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lisa Hartling
- Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
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Aronson PL, Thurm C, Williams DJ, Nigrovic LE, Alpern ER, Tieder JS, Shah SS, McCulloh RJ, Balamuth F, Schondelmeyer AC, Alessandrini EA, Browning WL, Myers AL, Neuman MI. Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age. J Hosp Med 2015; 10:358-65. [PMID: 25684689 PMCID: PMC4456211 DOI: 10.1002/jhm.2329] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/31/2014] [Accepted: 01/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN Retrospective cross-sectional study in 2013. SETTING Thirty-three hospitals in the Pediatric Health Information System. PATIENTS Infants aged ≤56 days with a diagnosis of fever. EXPOSURES The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.
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Affiliation(s)
- Paul L. Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Corresponding author Address correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-737-7443, Fax: 203-737-7447,
| | - Cary Thurm
- Children's Hospital Association, Overland Park, KS
| | - 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, TN
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joel S. Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Russell J. McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Fran Balamuth
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amanda C. Schondelmeyer
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Evaline A. Alessandrini
- James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Whitney L. Browning
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Angela L. Myers
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Leung JS, Perlman K, Rumantir M, Freedman SB. Emergency department ondansetron use in children with type 1 diabetes mellitus and vomiting. J Pediatr 2015; 166:432-8. [PMID: 25454931 DOI: 10.1016/j.jpeds.2014.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Revised: 08/25/2014] [Accepted: 10/03/2014] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To assess the hypothesis that ondansetron administration to children with type 1 diabetes mellitus (T1DM) presenting for emergency department (ED) care with intercurrent illness and vomiting improves clinical outcomes by reducing hospitalization rates (primary), length of ED stay, intravenous fluid (IVF) administration, and revisits (secondary outcomes). STUDY DESIGN We conducted a single-center, 10-year retrospective cohort study of 345 ED encounters of children aged 6 months-8 years with T1DM and vomiting. We compared outcomes among children receiving and not receiving ondansetron. To avoid selection bias related to ondansetron administration, we also investigated outcomes by conducting comparisons by ondansetron usage periods (ie, low [2002-2004] vs high [2009-2011]). RESULTS Ondansetron usage increased from 0% to 67% of ED encounters between 2002 and 2011. Admission rates were similar among those administered [54% (58/107)] and not administered ondansetron [55% (131/238)]. Length of stay was longer in children receiving ondansetron (409 vs 315 minutes; P = .03). IVF administration (77% vs 77%) and revisits (5.6% vs 5.9%) were similar. Ondansetron administration was not associated with reduced admission in logistic regression modeling. Admission rate (62%; 56/91 vs 49%; 57/111) (-13%, 95% CI -23%, 3%), length of stay (395 vs 327 minutes [IQR 164 501]; P < .001), and IVF administration decreased (84% [77/91] to 70% [78/111]; P = .02] when comparing low and high ondansetron usage periods. CONCLUSIONS Ondansetron administration was not independently associated with lower admission rates. Over time, along with increasing ondansetron use, there have been reductions in admissions, length of stay, and IVF administration in children with T1DM.
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Affiliation(s)
- James S Leung
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - Kusiel Perlman
- Division of Pediatric Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Division of Pediatric Emergency Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Stephen B Freedman
- Section of Pediatric Emergency Medicine, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada; Section of Pediatric Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, and Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
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Hu Z, Jin B, Shin AY, Zhu C, Zhao Y, Hao S, Zheng L, Fu C, Wen Q, Ji J, Li Z, Wang Y, Zheng X, Dai D, Culver DS, Alfreds ST, Rogow T, Stearns F, Sylvester KG, Widen E, Ling XB. Real-time web-based assessment of total population risk of future emergency department utilization: statewide prospective active case finding study. Interact J Med Res 2015; 4:e2. [PMID: 25586600 PMCID: PMC4319080 DOI: 10.2196/ijmr.4022] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Revised: 12/06/2014] [Accepted: 12/11/2014] [Indexed: 11/16/2022] Open
Abstract
Background An easily accessible real-time Web-based utility to assess patient risks of future emergency department (ED) visits can help the health care provider guide the allocation of resources to better manage higher-risk patient populations and thereby reduce unnecessary use of EDs. Objective Our main objective was to develop a Health Information Exchange-based, next 6-month ED risk surveillance system in the state of Maine. Methods Data on electronic medical record (EMR) encounters integrated by HealthInfoNet (HIN), Maine’s Health Information Exchange, were used to develop the Web-based surveillance system for a population ED future 6-month risk prediction. To model, a retrospective cohort of 829,641 patients with comprehensive clinical histories from January 1 to December 31, 2012 was used for training and then tested with a prospective cohort of 875,979 patients from July 1, 2012, to June 30, 2013. Results The multivariate statistical analysis identified 101 variables predictive of future defined 6-month risk of ED visit: 4 age groups, history of 8 different encounter types, history of 17 primary and 8 secondary diagnoses, 8 specific chronic diseases, 28 laboratory test results, history of 3 radiographic tests, and history of 25 outpatient prescription medications. The c-statistics for the retrospective and prospective cohorts were 0.739 and 0.732 respectively. Integration of our method into the HIN secure statewide data system in real time prospectively validated its performance. Cluster analysis in both the retrospective and prospective analyses revealed discrete subpopulations of high-risk patients, grouped around multiple “anchoring” demographics and chronic conditions. With the Web-based population risk-monitoring enterprise dashboards, the effectiveness of the active case finding algorithm has been validated by clinicians and caregivers in Maine. Conclusions The active case finding model and associated real-time Web-based app were designed to track the evolving nature of total population risk, in a longitudinal manner, for ED visits across all payers, all diseases, and all age groups. Therefore, providers can implement targeted care management strategies to the patient subgroups with similar patterns of clinical histories, driving the delivery of more efficient and effective health care interventions. To the best of our knowledge, this prospectively validated EMR-based, Web-based tool is the first one to allow real-time total population risk assessment for statewide ED visits.
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Affiliation(s)
- Zhongkai Hu
- College of Computer Science and Technology, Zhejiang University, Hangzhou, China
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Ondansetron and probiotics in the management of pediatric acute gastroenteritis in developed countries. Curr Opin Gastroenterol 2015; 31:1-6. [PMID: 25333367 DOI: 10.1097/mog.0000000000000132] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW Acute gastroenteritis (AGE) is a common and impactful disease, typically managed with supportive care. There is considerable interest in the role of adjunctive therapies, particularly ondansetron and probiotics in improving AGE outcomes. The purpose of this review is to present the latest evidence regarding the use of these agents in children with AGE in developed countries. RECENT FINDINGS Single-dose oral ondansetron is effective and safe in reducing hospital admissions and the use of intravenous rehydration in children with AGE in emergency-department-based trials. Ondansetron use has increased significantly; however, 'real-world' studies of effectiveness have documented less impressive clinical impacts. Similarly, probiotic consumption is growing rapidly. Although several strains appear to reduce the duration of diarrhea in hospitalized children, current data are insufficient to support the routine use of probiotics in outpatient pediatric AGE. SUMMARY Ondansetron and probiotics may improve patient outcomes in pediatric AGE. Appropriate strategies are needed to optimally integrate oral ondansetron into clinical practice to maximize its potential benefits. Although probiotics remain a promising option, there are challenges in generalizing the data available to patients presenting for outpatient care. Large randomized controlled trials are needed to definitively guide the clinical use of probiotics in outpatients in developed countries.
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Macias CG, Mansbach JM, Fisher ES, Riederer M, Piedra PA, Sullivan AF, Espinola JA, Camargo CA. Variability in inpatient management of children hospitalized with bronchiolitis. Acad Pediatr 2015; 15:69-76. [PMID: 25444654 DOI: 10.1016/j.acap.2014.07.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 07/18/2014] [Accepted: 07/19/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine the variability between hospitals in diagnostic testing and management interventions for children with bronchiolitis admitted to inpatient wards and identify its association with patient characteristics. METHODS A prospective, multicenter (16 hospitals), multiyear (2007-2010) observational study of children (age <2 years) hospitalized with bronchiolitis. Outcomes included variability in diagnostic testing (complete blood count, chest radiographs) and medications or interventions (bronchodilator, systemic corticosteroid, antibiotic, IV placement) by hospital. A modified Respiratory Distress Severity Score was utilized to assess severity of illness. For all outcomes, intraclass correlation coefficient (ICC) was calculated from a model to estimate the random effects of hospital without added covariates and compared to ICCs from a second model that adjusted for demographic and clinical patient characteristics. A second unadjusted and adjusted model was created for age ≥ 2 months. RESULTS Of 2207 subjects, 1715 were identified as admitted to inpatient wards. We observed wide variations in the proportion of patients who received diagnostic testing (complete blood count 21-75%, chest radiograph 36-85%) and medications/interventions (bronchodilators 19-91%, systemic corticosteroids 8-44%, antibiotics 17-43%, IV placement 38-93%). Adjusting for demographic and clinical patient characteristics did not materially affect the proportion of variability attributable to hospitals (differences in ICCs with and without model adjustment <4%). CONCLUSIONS Wide variations in diagnostic test utilization and management interventions seen among children with bronchiolitis treated on the inpatient wards at 16 US hospitals were not attributable to demographic or clinical patient characteristics. These results further support efforts to standardize care for bronchiolitis through active quality improvement strategies.
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Affiliation(s)
- Charles G Macias
- Department of Pediatrics, Section of Emergency Medicine, and Center for Clinical Effectiveness, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
| | - Jonathan M Mansbach
- Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, Mass
| | - Erin S Fisher
- Department of Pediatrics, Rady Children's Hospital, University of California, San Diego, Calif
| | - Mark Riederer
- Department of Pediatrics, Children's Hospital of Colorado, Denver, Colo
| | - Pedro A Piedra
- Departments of Molecular Virology and Microbiology, and Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Ashley F Sullivan
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Janice A Espinola
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
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Hao S, Jin B, Shin AY, Zhao Y, Zhu C, Li Z, Hu Z, Fu C, Ji J, Wang Y, Zhao Y, Dai D, Culver DS, Alfreds ST, Rogow T, Stearns F, Sylvester KG, Widen E, Ling XB. Risk prediction of emergency department revisit 30 days post discharge: a prospective study. PLoS One 2014; 9:e112944. [PMID: 25393305 PMCID: PMC4231082 DOI: 10.1371/journal.pone.0112944] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 10/16/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Among patients who are discharged from the Emergency Department (ED), about 3% return within 30 days. Revisits can be related to the nature of the disease, medical errors, and/or inadequate diagnoses and treatment during their initial ED visit. Identification of high-risk patient population can help device new strategies for improved ED care with reduced ED utilization. METHODS AND FINDINGS A decision tree based model with discriminant Electronic Medical Record (EMR) features was developed and validated, estimating patient ED 30 day revisit risk. A retrospective cohort of 293,461 ED encounters from HealthInfoNet (HIN), Maine's Health Information Exchange (HIE), between January 1, 2012 and December 31, 2012, was assembled with the associated patients' demographic information and one-year clinical histories before the discharge date as the inputs. To validate, a prospective cohort of 193,886 encounters between January 1, 2013 and June 30, 2013 was constructed. The c-statistics for the retrospective and prospective predictions were 0.710 and 0.704 respectively. Clinical resource utilization, including ED use, was analyzed as a function of the ED risk score. Cluster analysis of high-risk patients identified discrete sub-populations with distinctive demographic, clinical and resource utilization patterns. CONCLUSIONS Our ED 30-day revisit model was prospectively validated on the Maine State HIN secure statewide data system. Future integration of our ED predictive analytics into the ED care work flow may lead to increased opportunities for targeted care intervention to reduce ED resource burden and overall healthcare expense, and improve outcomes.
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Affiliation(s)
- Shiying Hao
- HBI Solutions Inc., Palo Alto, California, United States of America
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Bo Jin
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Andrew Young Shin
- Department of Pediatrics, Stanford University, Stanford, California, United States of America
| | - Yifan Zhao
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Chunqing Zhu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Zhen Li
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Zhongkai Hu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Changlin Fu
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Jun Ji
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Yong Wang
- Department of Statistics, Stanford University, Stanford, California, United States of America
- Academy of Mathematics and Systems Science, Chinese Academy of Sciences, Beijing, China
| | - Yingzhen Zhao
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Dorothy Dai
- HBI Solutions Inc., Palo Alto, California, United States of America
| | | | | | - Todd Rogow
- HealthInfoNet, Portland, Maine, United States of America
| | - Frank Stearns
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Karl G. Sylvester
- Department of Surgery, Stanford University, Stanford, California, United States of America
| | - Eric Widen
- HBI Solutions Inc., Palo Alto, California, United States of America
| | - Xuefeng B. Ling
- Department of Surgery, Stanford University, Stanford, California, United States of America
- * E-mail:
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Guse SE, Neuman MI, O'Brien M, Alexander ME, Berry M, Monuteaux MC, Fine AM. Implementing a guideline to improve management of syncope in the emergency department. Pediatrics 2014; 134:e1413-21. [PMID: 25332499 DOI: 10.1542/peds.2013-3833] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [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 Thirty-five percent of children experience syncope at least once. Although the etiology of pediatric syncope is usually benign, many children undergo low-yield diagnostic testing. We conducted a quality improvement intervention to reduce the rates of low-yield diagnostic testing for children presenting to an emergency department (ED) with syncope or presyncope. METHODS Children 8 to 22 years old presenting to a tertiary care pediatric ED with syncope or presyncope were included. We excluded children who were ill-appearing, had previously diagnosed cardiac or neurologic disease, ingestion, or trauma. We measured diagnostic testing rates among children presenting from July 2010 through October 2012, during which time we implemented a quality improvement intervention. Patient follow-up was performed 2 months after the ED visit to ascertain subsequent diagnostic testing and medical care. RESULTS A total of 349 patients were included. We observed a reduction in the rates of low-yield diagnostic testing after our quality improvement intervention: complete blood count testing decreased from 36% (95% confidence interval 29% to 43%) to 16% (12% to 22%) and electrolyte testing from 29% (23% to 36%) to 12% (8% to 17%). Performance of recommended testing increased, such as electrocardiograms and pregnancy testing in postpubertal girls. Despite a reduction in diagnostic testing among children with syncope, patients were not more likely to undergo subsequent diagnostic testing or seek further medical care following their ED visit. CONCLUSIONS Implementation of a quality improvement intervention for the ED evaluation of pediatric syncope was associated with reduced low-yield diagnostic testing, and was not associated with subsequent testing or medical care.
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Affiliation(s)
- Sabrina E Guse
- Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | - Megan O'Brien
- Department of Emergency Medicine, George Washington University, Washington, District of Columbia
| | - Mark E Alexander
- Cardiology, Boston Children's Hospital, Boston, Massachusetts; and
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Neuman MI, Alpern ER, Hall M, Kharbanda AB, Shah SS, Freedman SB, Aronson PL, Florin TA, Mistry RD, Berry JG. Characteristics of recurrent utilization in pediatric emergency departments. Pediatrics 2014; 134:e1025-31. [PMID: 25225134 DOI: 10.1542/peds.2014-1362] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Nationally, frequent utilizers of emergency departments (EDs) are targeted for quality improvement initiatives. The objective was to compare the characteristics and ED health services of children by their ED visit frequency. METHODS A retrospective study in 1,896,547 children aged 0 to 18 years with 3,263,330 visits to 37 EDs in 2011. The number of ED visits per child within 365 days of their first visit was counted. Patient characteristics (age, chronic condition) and ED care (medications, testing [laboratory and radiographic], and hospital admission) were assessed. We evaluated the relationship between patient characteristics and ED health services received with multivariable regression. RESULTS Children with ≥4 ED visits (8%) accounted for 24% of all visits and 31% ($1.4 billion) of all costs. As visit frequency increased from 1 to ≥4, the percentage of children aged <1 year increased (12.1% to 33.2%) and the percentage of children without a chronic condition decreased (81.9% to 45.6%) (P < .001 for both). Children with ≥4 ED visits had a higher percentage of visits without medication administration (aside from acetaminophen or ibuprofen), testing, or hospital admission when compared with children with 1 visit (35.4% vs 29.0%; P < .001). Children with ≥4 ED visits who were aged <1 year (odds ratio: 3.8; 95% confidence interval: 3.7-3.9) and who were without a chronic condition (odds ratio: 3.1; 95% confidence interval: 3.0-3.1) had the highest likelihood of experiencing this type of visit. CONCLUSIONS With a disproportionate share of pediatric ED cost and utilization, frequent utilizers, especially infants without a chronic condition, are the least likely to need medications, testing, and hospital admission.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts;
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Lurie Children's Hospital, Center of Healthcare Studies, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Anupam B Kharbanda
- Division of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, Minnesota
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Paul L Aronson
- Section of Emergency Medicine, Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut
| | - Todd A Florin
- Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Children's Hospital of Colorado, Denver, Colorado; and
| | - Jay G Berry
- Division of General Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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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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Bourgeois FT, Monuteaux MC, Stack AM, Neuman MI. Variation in emergency department admission rates in US children's hospitals. Pediatrics 2014; 134:539-45. [PMID: 25113291 PMCID: PMC4144003 DOI: 10.1542/peds.2014-1278] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. METHODS We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates. RESULTS A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates. CONCLUSIONS We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.
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Affiliation(s)
- Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
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Neuman MI, Hall M, Gay JC, Blaschke AJ, Williams DJ, Parikh K, Hersh AL, Brogan TV, Gerber JS, Grijalva CG, Shah SS. Readmissions among children previously hospitalized with pneumonia. Pediatrics 2014; 134:100-9. [PMID: 24958590 PMCID: PMC4531280 DOI: 10.1542/peds.2014-0331] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/09/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Pneumonia is a leading cause of hospitalization and readmission in children. Understanding the patient characteristics associated with pneumonia readmissions is necessary to inform interventions to reduce avoidable hospitalizations and related costs. The objective of this study was to characterize readmission rates, and identify factors and costs associated with readmission among children previously hospitalized with pneumonia. METHODS Retrospective cohort study of children hospitalized with pneumonia at the 43 hospitals included in the Pediatric Health Information System between January 1, 2008, and December 31, 2011. The primary outcome was all-cause readmission within 30 days after hospital discharge, and the secondary outcome was pneumonia-specific readmission. We used multivariable regression models to identify patient and hospital characteristics and costs associated with readmission. RESULTS A total of 82 566 children were hospitalized with pneumonia (median age, 3 years; interquartile range 1-7). Thirty-day all-cause and pneumonia-specific readmission rates were 7.7% and 3.1%, respectively. Readmission rates were higher among children <1 year of age, as well as in patients with previous hospitalizations, longer index hospitalizations, and complicated pneumonia. Children with chronic medical conditions were more likely to experience all-cause (odds ratio 3.0; 95% confidence interval 2.8-3.2) and pneumonia-specific readmission (odds ratio 1.8; 95% confidence interval 1.7-2.0) compared with children without chronic medical conditions. The median cost of a readmission ($11 344) was higher than that of an index admission ($4495; P = .01). Readmissions occurred in 8% of pneumonia hospitalizations but accounted for 16.3% of total costs for all pneumonia hospitalizations. CONCLUSIONS Readmissions are common after hospitalization for pneumonia, especially among young children and those with chronic medical conditions, and are associated with substantial costs.
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Affiliation(s)
- Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts;Department of Pediatrics, Harvard Medical School, Boston, Massachusetts;
| | - Matthew Hall
- The Children's Hospital Association, Overland Park, Kansas
| | | | - Anne J Blaschke
- Division of Infectious Diseases, Primary Children's Medical Center, Salt Lake City, Utah;Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Derek J Williams
- Departments of Pediatrics, andHospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Kavita Parikh
- Division of Hospital Medicine, Children's National Medical Center, Washington, District of Columbia;Department of Pediatrics, George Washington University School of Medicine, Washington, District of Columbia
| | - Adam L Hersh
- Division of Infectious Diseases, Primary Children's Medical Center, Salt Lake City, Utah;Departments of Pediatrics, and
| | - Thomas V Brogan
- Division of Critical Care, Seattle Children's Hospital, Seattle, Washington;Department of Pediatrics, University of Washington School of Medicine, Seattle, Washington
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Carlos G Grijalva
- Health Policy, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Samir S Shah
- Divisions of Infectious Diseases and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; andDepartment of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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