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Cadotte N, Moore H, Stone BL, Pershing NL, Ampofo K, Ou Z, Pavia AT, Blaschke AJ, Flaherty B, Crandall H. Prevalence of and Risks for Bacterial Infections in Hospitalized Children With Bronchiolitis. Hosp Pediatr 2024:e2023007549. [PMID: 38973365 DOI: 10.1542/hpeds.2023-007549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 03/19/2024] [Accepted: 03/19/2024] [Indexed: 07/09/2024]
Abstract
BACKGROUND AND OBJECTIVES Viral bronchiolitis is a common pediatric illness. Treatment is supportive; however, some children have concurrent serious bacterial infections (cSBIs) requiring antibiotics. Identifying children with cSBI is challenging and may lead to unnecessary treatment. Improved understanding of the prevalence of and risk factors for cSBI are needed to guide treatment. We sought to determine the prevalence of cSBI and identify factors associated with cSBI in children hospitalized with bronchiolitis. METHODS We performed a retrospective cohort study of children <2 years old hospitalized with bronchiolitis at a free-standing children's hospital from 2012 to 2019 identified by International Classification of Diseases codes. cSBI was defined as bacteremia, urinary tract infection, meningitis, or pneumonia. Risk factors for cSBI were identified using logistic regression. RESULTS We identified 7871 admissions for bronchiolitis. At least 1 cSBI occurred in 4.2% of these admissions; with 3.5% meeting our bacterial pneumonia definition, 0.4% bacteremia, 0.3% urinary tract infection, and 0.02% meningitis. cSBI were more likely to occur in children with invasive mechanical ventilation (odds ratio [OR] 2.53, 95% confidence interval [CI] 1.78-3.63), a C-reactive protein ≥4 mg/dL (OR 2.20, 95% CI 1.47-3.32), a concurrent complex chronic condition (OR 1.67, 95% CI 1.22-2.25) or admission to the PICU (OR 1.46, 95% CI 1.02-2.07). CONCLUSIONS cSBI is uncommon among children hospitalized with bronchiolitis, with pneumonia being the most common cSBI. Invasive mechanical ventilation, elevated C-reactive protein, presence of complex chronic conditions, and PICU admission were associated with an increased risk of cSBI.
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Affiliation(s)
- Noelle Cadotte
- Divisions of Critical Care
- Department of Pediatrics, Navy Medicine Readiness and Training Command, San Diego, California
| | - Hannah Moore
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Krow Ampofo
- Infectious Diseases, Department of Pediatrics
| | - Zhining Ou
- Epidemiology, Department of Internal Medicine
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Choi UY, Han SB. Antibiotic Use in Korean Children Diagnosed With Acute Bronchiolitis: Analysis of the National Health Insurance Reimbursement Data. J Korean Med Sci 2024; 39:e141. [PMID: 38711315 DOI: 10.3346/jkms.2024.39.e141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND Acute bronchiolitis, the most common lower respiratory tract infection in infants, is mostly caused by respiratory viruses. However, antibiotics are prescribed to about 25% of children with acute bronchiolitis. This inappropriate use of antibiotics for viral infections induces antibiotic resistance. This study aimed to determine the antibiotic prescription rate and the factors associated with antibiotic use in children with acute bronchiolitis in Korea, where antibiotic use and resistance rates are high. METHODS Healthcare data of children aged < 24 months who were diagnosed with acute bronchiolitis between 2016 and 2019 were acquired from the National Health Insurance system reimbursement claims data. Antibiotic prescription rates and associated factors were evaluated. RESULTS A total of 3,638,424 visits were analyzed. The antibiotic prescription rate was 51.8%, which decreased over time (P < 0.001). In the multivariate analysis, toddlers (vs. infants), non-capital areas (vs. capital areas), primary clinics and non-tertiary hospitals (vs. tertiary hospitals), inpatients (vs. outpatients), and non-pediatricians (vs. pediatricians) showed a significant association with antibiotic prescription (P < 0.001). Fourteen cities and provinces in the non-capital area exhibited a wide range of antibiotic prescription rates ranging from 41.2% to 65.4%, and five (35.7%) of them showed lower antibiotic prescription rates than that of the capital area. CONCLUSION In Korea, the high antibiotic prescription rates for acute bronchiolitis varied by patient age, region, medical facility type, clinical setting, and physician specialty. These factors should be considered when establishing strategies to promote appropriate antibiotic use.
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Affiliation(s)
- Ui Yoon Choi
- Department of Pediatrics, Eunpyeong St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seung Beom Han
- Department of Pediatrics, Hangang Sacred Heart Hospital, College of Medicine, Hallym University, Seoul, Korea.
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Mellick LB. The De-implementation of Bronchiolitis Medications: Is It Time for a Moratorium? Pediatr Emerg Care 2024; 40:e30-e32. [PMID: 37665971 DOI: 10.1097/pec.0000000000003049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Affiliation(s)
- Larry B Mellick
- Department of Emergency Medicine, Augusta University, Augusta, GA
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House SA, Marin JR, Coon ER, Ralston SL, Hall M, Gruhler De Souza H, Ho T, Reyes M, Schroeder AR. Trends in Low-Value Care Among Children's Hospitals. Pediatrics 2024; 153:e2023062492. [PMID: 38130171 DOI: 10.1542/peds.2023-062492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/19/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends. METHODS This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC. RESULTS There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures. CONCLUSIONS LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.
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Affiliation(s)
- Samantha A House
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, and New Hampshire Dartmouth Health Children's, Lebanon, New Hampshire
| | - Jennifer R Marin
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Eric R Coon
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Shawn L Ralston
- Department of Pediatrics, University of Washington, Seattle, Washington
| | | | | | - Timmy Ho
- Department of Neonatology, Beth Israel Deaconess Medical Center; Harvard Medical School, Boston, Massachusetts
| | - Mario Reyes
- Department of Pediatrics, Division of Hospital Medicine, Nicklaus Children's Hospital, Miami, Florida
| | - Alan R Schroeder
- Department of Pediatrics, Stanford University, Stanford, California
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Walsh PS, Wendt WJ, Lipshaw MJ. Asthmalitis? Diagnostic Variability of Asthma and Bronchiolitis in Children <24 Months. Hosp Pediatr 2024; 14:59-66. [PMID: 38146264 DOI: 10.1542/hpeds.2023-007359] [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: 12/27/2023]
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis and asthma have similar acute clinical presentations in young children yet have opposing treatment recommendations. We aimed to assess the role of age and other factors in the diagnosis of bronchiolitis and asthma in children <24 months of age. METHODS We conducted a retrospective cross-sectional analysis of the Pediatric Health Information System database. We included children aged <2 years diagnosed with bronchiolitis, asthma, wheeze, or bronchospasm in emergency department or hospital encounters from 2017 to 2021. We described variation by age and between institutions. We used mixed-effects models to assess factors associated with a non-bronchiolitis diagnosis in children 12 to 23 months of age. RESULTS We included 554 158 encounters from 42 hospitals. Bronchiolitis made up 98% of encounters for children <3 months of age, whereas asthma diagnoses increased with age and were included in 44% of encounters at 23 months of age. Diagnosis patterns varied widely between hospitals. In children 12 to 23 months of age, the odds of a non-bronchiolitis diagnosis increased with month of age (odds ratio [OR] 1.13, 95% confidence interval [CI] 1.12-1.13), male sex (OR 1.37, 95% CI 1.35-1.40), non-Hispanic Black race (OR 1.54, 95% CI 1.50-1.58), number of previous encounters (OR 2.73, 95% CI 2.61-2.86, for 3 or more encounters), and previous albuterol use (OR 2.24, 95% CI 2.16-2.32). CONCLUSIONS Non-bronchiolitis diagnoses and the use of inhaled bronchodilators and systemic steroids for acute wheezing respiratory illness increase with month of age in children aged 0 to 23 months. Better definitions of clinical phenotypes of bronchiolitis and asthma would allow for more appropriate treatment in acute care settings, particularly in children 12 to 23 months of age.
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Affiliation(s)
- Patrick S Walsh
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Wendi-Jo Wendt
- Department of Pediatrics, Section of Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Matthew J Lipshaw
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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DeSanti RL, Gill KG, Swanson JO, Kory PD, Schmidt J, Cowan EA, Lasarev MR, Al-Subu AM. Comparison of chest radiograph and lung ultrasound in children with acute respiratory failure. J Ultrasound 2023; 26:861-870. [PMID: 37747593 PMCID: PMC10632347 DOI: 10.1007/s40477-023-00827-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 08/17/2023] [Indexed: 09/26/2023] Open
Abstract
PURPOSE Chest x-ray (CXR) is the standard imaging used to evaluate children in acute respiratory distress and failure. Our objective was to compare the lung-imaging techniques of CXR and lung ultrasound (LUS) in the evaluation of children with acute respiratory failure (ARF) to quantify agreement and to determine which technique identified a higher frequency of pulmonary abnormalities. METHODS This was a secondary analysis of a prospective observational study evaluating the sensitivity and specificity of LUS in children with ARF from 12/2018 to 02/2020 completed at the University of Wisconsin-Madison (USA). Children > 37.0 weeks corrected gestational age and ≤ 18 years of age admitted to the PICU with ARF were evaluated with LUS. We compared CXR and LUS completed within 6 h of each other. Kappa statistics (k) adjusted for maximum attainable agreement (k/kmax) were used to quantify agreement between imaging techniques and descriptive statistics were used to describe the frequency of abnormalities. RESULTS Eighty-eight children had LUS completed, 32 with concomitant imaging completed within 6 h are included. There was fair agreement between LUS and CXR derived diagnoses with 58% agreement (k/kmax = 0.36). Evaluation of imaging patterns included: normal, 57% agreement (k = 0.032); interstitial pattern, 47% agreement (k = 0.003); and consolidation, 65% agreement (k = 0.29). CXR identified more imaging abnormalities than LUS. CONCLUSIONS There is fair agreement between CXR and LUS-derived diagnoses in children with ARF. Given this, clinicians should consider the benefits and limitations of specific imaging modalities when evaluating children with ARF. Additional studies are necessary to further define the role of LUS in pediatric ARF given the small sample size of our study.
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Affiliation(s)
- Ryan L DeSanti
- Department of Pediatrics, Drexel College of Medicine, St Christopher's Hospital for Children, Philadelphia, PA, USA.
- Department of Critical Care Medicine, St Christopher's Hospital for Children, 160 East Erie Avenue, Third Floor Suite, Office A3-20k, Philadelphia, PA, 19143, USA.
| | - Kara G Gill
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Jonathan O Swanson
- Department of Radiology, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Pierre D Kory
- Department of Medicine, Advocate Aurora Health Care, St Luke's Medical Center, Milwaukee, WI, USA
| | - Jessica Schmidt
- Department of Emergency Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Eileen A Cowan
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Michael R Lasarev
- Department of Biostatistics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Awni M Al-Subu
- Department of Pediatrics, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
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Schuh S, Coates AL, Sweeney J, Rumantir M, Eltorki M, Alqurashi W, Plint AC, Zemek R, Poonai N, Parkin PC, Soares D, Moineddin R, Finkelstein Y. Nasal Suctioning Therapy Among Infants With Bronchiolitis Discharged Home From the Emergency Department: A Randomized Clinical Trial. JAMA Netw Open 2023; 6:e2337810. [PMID: 37856126 PMCID: PMC10587796 DOI: 10.1001/jamanetworkopen.2023.37810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/18/2023] [Indexed: 10/20/2023] Open
Abstract
Importance Although nasal suctioning is the most frequently used supportive management for bronchiolitis, its benefit remains unknown. Objective To evaluate the effectiveness of enhanced vs minimal nasal suctioning in treating infants with bronchiolitis after discharge from the emergency department (ED). Design, Setting, and Participants This single-blind, parallel-group, randomized clinical trial was conducted from March 6, 2020, to December 15, 2022, at 4 tertiary-care Canadian pediatric EDs. Participants included otherwise healthy infants aged 1 to 11 months with a diagnosis of bronchiolitis who were discharged home from the ED. Interventions Participants were randomized to minimal suctioning via bulb or enhanced suctioning via a battery-operated device before feeding for 72 hours. Main Outcomes and Measures The primary outcome was additional resource use, a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding and/or breathing concerns. Secondary outcomes included health care utilization, feeding and sleeping adequacy, and satisfaction. Results Of 884 screened patients, 352 were excluded for criteria, 79 declined participation, 81 were otherwise excluded, 372 were randomized (185 to the minimal suction group and 187 to the enhanced suction group), and 367 (median [IQR] age, 4 [2-6] months; 221 boys [60.2%]) completed the trial (184 in the minimal suction and 183 in the enhanced suction group). Additional resource use occurred for 68 of 184 minimal suction participants (37.0%) vs 48 of 183 enhanced suction participants (26.2%) (absolute risk difference, 0.11; 95% CI, 0.01 to 0.20; P = .03). Unscheduled revisits occurred for 47 of 184 minimal suction participants (25.5%) vs 40 of 183 enhanced suction participants (21.9%) (absolute risk difference, 0.04; 95% CI, -0.05 to 0.12; P = .46). A total of 33 of 184 parents in the minimal suction group (17.9%) used additional suctioning devices vs 11 of 183 parents in the enhanced suction group (6.0%) (absolute risk difference, 0.12; 95% CI, 0.05 to 0.19; P < .001). No significant between-group differences were observed for all bronchiolitis revisits (absolute risk difference, 0.07; 95% CI, -0.02 to 0.16; P = .15), ED revisits (absolute risk difference, 0.04; 95% CI, -0.03 to 0.12; P = .30), parental care satisfaction (absolute risk difference, -0.02; 95% CI, -0.10 to 0.06; P = .70), and changes from baseline to 72 hours in normal feeding (difference in differences, 0.03; 95% CI, -0.10 to 0.17; P = .62), normal sleeping (difference in differences, 0.05; 95% CI, -0.08 to 0.18; P = .47), or normal parental sleeping (difference in differences, 0.10; 95% CI, -0.02 to 0.23; P = .09). Parents in the minimal suction group were less satisfied with the assigned device (62 of 184 [33.7%]) than parents in the enhanced suction group (145 of 183 [79.2%]) (risk difference, 0.45; 95% CI, 0.36 to 0.54; P < .001). Conclusions and Relevance Compared with minimal suctioning, enhanced suctioning after ED discharge with bronchiolitis did not alter the disease course because there were no group differences in revisits or feeding and sleeping adequacy. Minimal suctioning resulted in higher use of nonassigned suctioning devices and lower parental satisfaction with the assigned device. Trial Registration ClinicalTrials.gov Identifier: NCT03361371.
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Affiliation(s)
- Suzanne Schuh
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Allan L. Coates
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Judy Sweeney
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Maggie Rumantir
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mohamed Eltorki
- Division of Pediatric Emergency Medicine, McMaster Children’s Hospital, Hamilton Health Sciences, Hamilton, Ontario, Canada
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alqurashi
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Amy C. Plint
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Roger Zemek
- Department of Pediatrics and Emergency Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
- CHEO Research Institute, Ottawa, Ontario, Canada
| | - Naveen Poonai
- Department of Paediatrics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
- Children’s Health Research Institute, University of Western Ontario, London, Ontario, Canada
| | - Patricia C. Parkin
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Diane Soares
- Department of Respiratory Therapy, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Research Institute, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
- Division of Clinical Pharmacology and Toxicology, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Outram SM, Rooholamini SN, Desai M, Edwards Y, Ja C, Morton K, Vaughan JH, Shaw JS, Gonzales R, Kaiser SV. Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals. Hosp Pediatr 2023; 13:931-939. [PMID: 37697946 PMCID: PMC10520265 DOI: 10.1542/hpeds.2023-007173] [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] [Indexed: 09/13/2023]
Abstract
BACKGROUND An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework. METHODS We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework. RESULTS Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling. CONCLUSIONS We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.
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Affiliation(s)
- Simon M. Outram
- Department of Pediatrics, University of California, San Francisco, California
| | | | - Mansi Desai
- Department of Pediatrics, University of California, San Francisco, California
| | - Yeelen Edwards
- Department of Pediatrics, University of California, San Francisco, California
| | | | - Kayce Morton
- Department of Pediatrics, CoxHealth, Springfield, Missouri
- Department of Pediatrics, University of Missouri, Columbia, Missouri
| | - Jordan H. Vaughan
- Department of Pediatrics, University of California, San Francisco, California
| | - Judith S. Shaw
- Department of Pediatrics, University of Vermont, Burlington, Vermont
| | - Ralph Gonzales
- Department of Pediatrics, University of California, San Francisco, California
| | - Sunitha V. Kaiser
- Department of Pediatrics, University of California, San Francisco, California
- Philip R. Lee Institute for Health Policy Studies, San Francisco, California
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McLaren SH, Qi Y(S, Espinola JA, Mansbach JM, Dayan PS, Camargo CA. Factors associated with mild bronchiolitis in young infants. J Am Coll Emerg Physicians Open 2023; 4:e12966. [PMID: 37206982 PMCID: PMC10189080 DOI: 10.1002/emp2.12966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/24/2023] [Accepted: 04/19/2023] [Indexed: 05/21/2023] Open
Abstract
Objective Bronchiolitis within the first 3 months of life is a risk factor for more severe illness. We aimed to identify characteristics associated with mild bronchiolitis in infants ≤90 days old presenting to the emergency department (ED). Methods We conducted a secondary analysis of infants ≤90 days old with clinically diagnosed bronchiolitis using data from the 25th Multicenter Airway Research Collaboration prospective cohort study. We excluded infants with direct intensive care unit admissions. Mild bronchiolitis was defined as (1) sent home after the index ED visit and did not have a return ED visit or had a return ED visit without hospitalization, or (2) were hospitalized from the index ED visit to the inpatient floor for <24 hours. Multivariable logistic regression, adjusting for potential clustering by hospital site, was used to identify factors associated with mild bronchiolitis. Results Of 373 infants aged ≤90 days, 333 were eligible for analysis. Of these, 155 (47%) infants had mild bronchiolitis, and none required mechanical ventilation. Adjusting for infant characteristics, clinical factors associated with mild bronchiolitis included older age (61-90 days vs 0-60 days) (odds ratio [OR] 2.72, 95% confidence interval [CI] 1.52-4.87), adequate oral intake (OR 4.48, 95% CI 2.08-9.66), and lowest ED oxygen saturation ≥94% (OR 3.12, 95% CI 1.55-6.30). Conclusions Among infants aged ≤90 days presenting to the ED with bronchiolitis, about half had mild bronchiolitis. Mild illness was associated with older age (61-90 days), adequate oral intake, and oxygen saturation ≥94%. These predictors may help in the development of strategies to limit unnecessary hospitalization in young infants with bronchiolitis.
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Affiliation(s)
- Son H. McLaren
- Department of Emergency MedicineColumbia University Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Ying (Shelly) Qi
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | - Janice A. Espinola
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
| | | | - Peter S. Dayan
- Department of Emergency MedicineColumbia University Vagelos College of Physicians and SurgeonsNew YorkNew YorkUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalHarvard Medical SchoolBostonMassachusettsUSA
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10
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Biagi C, Betti L, Manieri E, Dondi A, Pierantoni L, Ramanathan R, Zama D, Gennari M, Lanari M. Different Pediatric Acute Care Settings Influence Bronchiolitis Management: A 10-Year Retrospective Study. Life (Basel) 2023; 13:life13030635. [PMID: 36983790 PMCID: PMC10056632 DOI: 10.3390/life13030635] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 01/13/2023] [Accepted: 02/21/2023] [Indexed: 02/26/2023] Open
Abstract
Bronchiolitis is the main cause of hospitalization in infants. Diagnosis is clinical, and treatment is based on hydration and oxygen therapy. Nevertheless, unnecessary diagnostic tests and pharmacological treatments are still very common. This retrospective study aimed to evaluate whether the setting of bronchiolitis care influences diagnostic and therapeutic choices. The management of 3201 infants, referred to our Italian Tertiary Care Center for bronchiolitis between 2010 and 2020, was analyzed by comparing children discharged from the pediatric emergency department (PEDd group) undergoing short-stay observation (SSO group) and hospitalization. Antibiotic use in PEDd, SSO, and ward was 59.3% vs. 51.6% vs. 49.7%, respectively (p < 0.001); inhaled salbutamol was mainly administered in PEDd and during SSO (76.1% and 82.2% vs. 38.3% in ward; p < 0.001); the use of corticosteroids was higher during SSO and hospitalization (59.6% and 49.1% vs. 39.0% in PEDd; p < 0.001); inhaled adrenaline was administered mostly in hospitalized infants (53.5% vs. 2.5% in SSO and 0.2% in PEDd; p < 0.001); chest X-ray use in PEDd, SSO, and ward was 30.3% vs. 49.0% vs. 70.5%, respectively (p < 0.001). In a multivariate analysis, undergoing SSO was found to be an independent risk factor for the use of systemic corticosteroid and salbutamol; being discharged at home was found to be a risk factor for antibiotic prescription; undergoing SSO and hospitalization resulted as independent risk factors for the use of CXR. Our study highlights that different pediatric acute care settings could influence the management of bronchiolitis. Factors influencing practice may include a high turnover of PED medical staff, personal reassurance, and parental pressure.
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Affiliation(s)
- Carlotta Biagi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Correspondence: (C.B.); (L.B.)
| | - Ludovica Betti
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
- Correspondence: (C.B.); (L.B.)
| | - Elisa Manieri
- Specialty School of Pediatrics, Alma Mater Studiorum, University of Bologna, 40126 Bologna, Italy
| | - Arianna Dondi
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Luca Pierantoni
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Ramsiya Ramanathan
- Infectious Diseases Unit, Fondazione IRCCS Ca’ Granda—Ospedale Maggiore Policlinico, 20122 Milano, Italy
| | - Daniele Zama
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Monia Gennari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
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11
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Freed GL, Wickham KL. Assessing the pediatric subspecialty pipeline: it is all about the data source. Pediatr Res 2022:10.1038/s41390-022-02438-5. [PMID: 36564480 DOI: 10.1038/s41390-022-02438-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 11/11/2022] [Accepted: 11/17/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND National Resident Match Program (NRMP) data are often used to identify the pediatric subspecialty pipeline. Other data sources may provide greater accuracy. METHODS Analysis of data from the NRMP and the American Board of Pediatrics (ABP) for 14 pediatric subspecialties from 2008 to 2020. We calculated, within each subspecialty, the annual number of first-year fellowship positions offered, the NRMP match rate, the actual number of fellows entering training (ABP data) relative to the number of positions in the match (fill rate), and the actual number of matriculating first-year fellows each year. RESULTS For all subspecialties and years, the fill rate was greater than the match rate. All subspecialties had an increase in the relative and absolute number of first-year fellows, with the largest increases seen in emergency medicine (73.3%) and critical care (68.9%). Except for adolescent medicine, all subspecialties had an absolute increase in the number of positions offered, with the largest increase in pulmonology (32.1%). CONCLUSIONS NRMP data underestimate the actual number of first-year fellows entering subspecialty training. For all subspecialties, the number of first-year fellows has increased over time, indicating continued expansion in the pipeline for most. However, there remains great variation across subspecialties. IMPACT Perceptions of the pipeline for the pediatric subspecialty workforce vary depending on the data source. The use of NMRP match data alone underestimates the number of matriculating trainees. The number of unmatched fellowship positions has created a perception of a diminishing number of pediatric subspecialty fellows. This study uses multiple data sources to better understand the actual number of fellows entering pediatric subspecialty training and demonstrates that the NRMP match rate alone underestimates the pipeline of the pediatric subspecialty workforce.
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Affiliation(s)
- Gary L Freed
- Department of Pediatrics, Division of General Pediatrics, Susan B. Meister Child Health Evaluation and Research Center (CHEAR), University of Michigan Health Systems, Ann Arbor, MI, USA.
| | - Kyle L Wickham
- University of Michigan Medical School, Ann Arbor, MI, USA
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12
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Lirette MP, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Florin TA, Babl FE, Dalziel S, Freedman S, Roland D, Lyttle MD, Schnadower D, Steele D, Fernandes RM, Stephens D, Kharbanda A, Johnson DW, Macias C, Benito J, Schuh S. International variation in evidence-based emergency department management of bronchiolitis: a retrospective cohort study. BMJ Open 2022; 12:e059784. [PMID: 36600373 PMCID: PMC9730363 DOI: 10.1136/bmjopen-2021-059784] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES We aimed to evaluate the international variation in the use of evidence-based management (EBM) in bronchiolitis. We hypothesised that management consistent with full-EBM practices is associated with the research network of care, adjusted for patient-level characteristics. Secondary objectives were to determine the association between full-EBM and (1) hospitalisation and (2) emergency department (ED) revisits resulting in hospitalisation within 21 days. DESIGN A secondary analysis of a retrospective cohort study. SETTING 38 paediatric EDs belonging to the Paediatric Emergency Research Network in Canada, USA, Australia/New Zealand UK/Ireland and Spain/Portugal. PATIENTS Otherwise healthy infants 2-11 months old diagnosed with bronchiolitis between 1 January 2013 and 31 December, 2013. OUTCOME MEASURES Primary outcome was management consistent with full-EBM, that is, no bronchodilators/corticosteroids/antibiotics, no chest radiography or laboratory testing. Secondary outcomes included hospitalisations during the index and subsequent ED visits. RESULTS 1137/2356 (48.3%) infants received full-EBM (ranging from 13.2% in Spain/Portugal to 72.3% in UK/Ireland). Compared with the UK/Ireland, the adjusted ORs (aOR) of full-EBM receipt were lower in Spain/Portugal (aOR 0.08, 95% CI 0.02 to 0.29), Canada (aOR 0.13 (95% CI 0.06 to 0.31) and USA (aOR 0.16 (95% CI 0.07 to 0.35). EBM was less likely in infants with dehydration (aOR 0.49 (95% CI 0.33 to 0.71)), chest retractions (aOR 0.69 (95% CI 0.52 to 0.91)) and nasal flaring (aOR 0.69 (95% CI 0.52 to 0.92)). EBM was associated with reduced odds of hospitalisation at the index visit (aOR 0.77 (95% CI 0.60 to 0.98)) but not at revisits (aOR 1.17 (95% CI 0.74 to 1.85)). CONCLUSIONS Infants with bronchiolitis frequently do not receive full-EBM ED management, particularly those outside of the UK/Ireland. Furthermore, there is marked variation in full-EBM between paediatric emergency networks, and full-EBM delivery is associated with lower likelihood of hospitalisation. Given the global bronchiolitis burden, international ED-focused deimplementation of non-indicated interventions to enhance EBM is needed.
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Affiliation(s)
- Marie-Pier Lirette
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Nathan Kuppermann
- The Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
- University of California Davis Health System, Sacramento, California, USA
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
- Division of Pediatric Emergency Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Todd Adam Florin
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Pediatrics, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Franz E Babl
- Emergency Department, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
- The University of Melbourne/The Royal Children's Hospital CICH, Parkville, Victoria, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, Auckland, New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - Stephen Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic (PEMLA) Group, Leicester Royal Infirmary, Leicester, UK
- SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Mark David Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK
- Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, UK
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Dale Steele
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, Rhode Island, USA
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Brown University, Providence, Rhode Island, USA
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria, Lisboa, Portugal
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Universidade de Lisboa Instituto de Medicina Molecular, Lisboa, Portugal
| | - Derek Stephens
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota, USA
| | - David W Johnson
- University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
| | - Charles Macias
- Division of Pediatric Emergency Medicine, UH Rainbow Babies and Children's Hospital, Cleveland, Ohio, USA
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain
| | - Suzanne Schuh
- Hospital for Sick Children Research Institute, University of Toronto, Toronto, Ontario, Canada
- Division of Pediatric Emergency Medicine, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
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13
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Montejo M, Paniagua N, Pijoan JI, Saiz-Hernando C, Castelo S, Martin V, Sánchez A, Benito J. Reducing Unnecessary Treatment of Bronchiolitis Across a Large Regional Health Service in Spain. Pediatrics 2022; 150:189721. [PMID: 36222087 DOI: 10.1542/peds.2021-053888] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2022] [Indexed: 02/25/2023] Open
Abstract
OBJECTIVES A bronchiolitis integrated care pathway (BICP) proved useful in reducing the use of unnecessary medications at a local level. The aim of this study was to reduce overtreatment by scaling up the BICP across our regional health service in the 2019 and 2020 bronchiolitis season. METHODS We conducted a quality improvement (QI) initiative in 115 primary care (PC) centers and 7 hospitals in the Basque Country, Spain, from October 2019 to March 2020. The primary outcome measure was the percentage of children prescribed salbutamol comparing the rate to that in the previous bronchiolitis season (October 2018-March 2019). Secondary outcomes were the use of other medications. Balancing measures were hospitalization and unscheduled return rates. RESULTS We included 8153 PC visits, 3424 emergency department (ED) attendances, and 663 inpatient care episodes, of which 3817 (46.8%), 1614 (47.1%), and 328 (49.4%) occurred in the postintervention period, respectively. Salbutamol use decreased from 27.1% to 4.7%, 29.5% to 3.0%, and 44.4% to 3.9% (P < .001) in PC centers, Eds, and hospital wards, respectively. In PC, corticosteroid and antibiotic prescribing rates fell from 10.1% to 1.7% and 13.7% to 5.1%, respectively (P < .001). In EDs and hospital wards, epinephrine use rates fell from 14.2% to 4.2% (P < .001) and 30.4% to 19.8% (P = .001), respectively. No variations were noted in balancing measures. CONCLUSIONS The scaling up of the BICP was associated with significant decreases in the use of medications in managing bronchiolitis across a regional health service without unintended consequences.
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Affiliation(s)
| | | | | | | | | | | | - Alvaro Sánchez
- Primary Care Research Department, Biocruces Bizkaia Health Research Institute, Biscay, Basque Country, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital
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14
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Navanandan N, McNulty MC, Suresh K, Freeman J, Scherer LD, Tyler A. Factors Associated With Clinician Self-Reported Resource Use in Acute Care and Ambulatory Pediatrics. Clin Pediatr (Phila) 2022; 62:329-337. [PMID: 36199256 PMCID: PMC10073349 DOI: 10.1177/00099228221128074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The objective of this study is to determine predictors of resource use among pediatric providers for common respiratory illnesses. We surveyed pediatric primary care, emergency department (ED)/urgent care (UC), and hospital medicine providers at a free-standing children's hospital system. Five clinical vignettes assessed factors affecting resource use for upper respiratory infections, bronchiolitis, and pneumonia, including provider-type, practice location, tolerance to uncertainty, and medical decision-making behaviors. The response rate was 75.3% (168/223). The ED/UC and primary care providers had higher vignette scores, indicating higher resource use, compared with inpatient providers; advanced practice providers (APPs) had higher vignette scores compared with physicians. In multivariate analysis, being an ED/UC provider, an APP, and greater concern for bad outcomes were associated with higher vignette scores. Overall, provider type and location of practice may predict resource use for children with respiratory illnesses. Interventions targeted at test-maximizing providers may improve quality of care and reduce resource burden.
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Affiliation(s)
- Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Monica C McNulty
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA
| | - Krithika Suresh
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Biostatistics and Informatics, University of Colorado School of Public Health, Aurora, CO, USA
| | - Julia Freeman
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Aurora, CO, USA.,Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Laura D Scherer
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Amy Tyler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA.,Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado, Aurora, CO, USA.,Section of Pediatric Hospital Medicine, Children's Hospital of Colorado, Aurora, CO, USA
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15
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Bronchiolitis therapies and misadventures. Paediatr Respir Rev 2022:S1526-0542(22)00066-5. [PMID: 36280580 DOI: 10.1016/j.prrv.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/26/2022] [Indexed: 11/21/2022]
Abstract
Viral bronchiolitis, which is most commonly caused by an infection with the respiratory syncytial virus (RSV), can lead to respiratory difficulties in young children which may require hospitalization. Despite years of research and medical trials, the mainstay of bronchiolitis treatment remains supportive only. This review provides an overview of the history of different treatments for bronchiolitis, including those that failed, as well as new therapies that are under study. Future studies for the treatment of bronchiolitis should consider different age-groups, important subgroups (i.e., those with a prior history of wheezing, those with a family history of asthma and those with non-RSV viral etiologies) whose response to treatment may differ from that of the composite group.
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16
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Elks M, Young J, Kearney L, Bernard A. The impact of an autonomous nurse-led high-flow nasal cannula oxygen protocol on clinical outcomes of infants with bronchiolitis. J Clin Nurs 2022. [PMID: 36164265 DOI: 10.1111/jocn.16525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 08/01/2022] [Accepted: 08/14/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To investigate the relationship of the implementation of a nurse-led high-flow nasal cannula oxygen protocol on the clinical outcomes of infants with bronchiolitis in a regional paediatric unit. BACKGROUND Bronchiolitis is a common lower respiratory illness and is the leading cause for hospitalisation of infants globally. Standard care involves the provision of supportive measures. Historically, supplemental oxygen was provided by low-flow nasal cannula. High-flow nasal cannula oxygen has been increasingly adopted despite limited evidence of its efficacy. METHODS This study employed non-equivalent, post-implementation only design to explore clinical outcomes of infants with bronchiolitis admitted for high-flow nasal cannula oxygen therapy. The study compared infants in the 24 months before and after the initiation of a high-flow nasal cannula protocol. The primary clinical outcome was length of stay, secondary outcomes included time on high flow, weaning time, escalation of care and time outside of physiological parameters. Implementation strategy evaluation was measured by compliance with applying the protocol, reported as episodes of variance, and duration of variance. The StaRI checklist was selected as the most appropriate reporting guideline. RESULTS A total of 80 patients were admitted with bronchiolitis and received high-flow nasal cannula oxygen therapy during a 48-month period; 37 patients were prior, and 43 after, the introduction of a nurse-led high-flow nasal cannula protocol. Length of stay was significantly reduced in the post-implementation group compared to the historical control group (83.8 vs. 61.3 h). Time on high flow and weaning time was decreased in the post-implementation group compared to the control group (33.5 vs. 26.7 h and 26 vs.12.25 h, respectively); however, these did not reach statistical significance. There was varied application of the HFNC protocol. CONCLUSIONS The implementation of a nurse-led high-flow nasal cannula protocol was associated with a reduced length of stay. RELEVANCE TO CLINICAL PRACTICE This study demonstrated that infants with bronchiolitis that were treated with a nurse-led high-flow nasal cannula (HFNC) therapy protocol had positive effects on clinical outcomes including a shorter length of stay than compared with those with physician-directed care in a regional paediatric unit. A weight-based (2 L/kg) HFNC therapy was safely administered to infants with bronchiolitis in a regional hospital paediatric ward with no paediatric intensive care unit (PICU).
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Affiliation(s)
- Michelle Elks
- Sunshine Coast Hospital and Health Service, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Jeanine Young
- School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Lauren Kearney
- School of Nursing, Midwifery & Paramedicine University of the Sunshine Coast, Sunshine Coast, Queensland, Australia
| | - Anne Bernard
- Institute for Molecular Bioscience, The University of Queensland, Brisbane, Australia
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17
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Bakel LA, Richardson T, De Souza HG, Kaiser SV, Mahant S, Treasure JD, Waynik IY, Winer JC, Bajaj L. Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions. J Hosp Med 2022; 17:417-426. [PMID: 35535935 DOI: 10.1002/jhm.12811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 02/11/2022] [Accepted: 02/19/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.
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Affiliation(s)
- Leigh Anne Bakel
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | | | | | - Sunitha V Kaiser
- Department of Pediatrics, University of California at San Francisco, San Francisco, California, USA
| | - Sanjay Mahant
- Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Jennifer D Treasure
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Ilana Y Waynik
- Department of Pediatrics, Connecticut Children's Medical Center, University of Connecticut, Mansfield, Connecticut, USA
| | - Jeffrey C Winer
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lalit Bajaj
- Section of Hospital Medicine, Department of Pediatrics, Clinical Effectiveness Team, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
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18
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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 DOI: 10.1002/jhm.12833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [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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19
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Andina Martínez D, Escalada Pellitero S, Viaño Nogueira P, Alonso Cadenas JA, Martín Díaz MJ, de la Torre-Espi M, Jiménez García R. Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 96:476-484. [DOI: 10.1016/j.anpede.2021.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 05/05/2021] [Indexed: 11/29/2022] Open
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20
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Confirming racial/ethnic disparities in the management of severe bronchiolitis. Am J Emerg Med 2022; 58:333-335. [PMID: 35370036 DOI: 10.1016/j.ajem.2022.03.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 03/24/2022] [Indexed: 11/22/2022] Open
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Abstract
OBJECTIVES To evaluate the contribution of PICU care to increasing hospital charges for patients with bronchiolitis over a 10-year study period. DESIGN In this retrospective multicenter study, changes in annual hospital charges (adjusted for inflation) were analyzed using linear regression for subjects admitted to the PICU with invasive mechanical ventilation (PICU + IMV) and without IMV (PICU - IMV), and for children not requiring PICU care. SETTING Free-standing children's hospitals contributing to the Pediatric Health Information System (PHIS) database. SUBJECTS Children less than 2 years with bronchiolitis discharged from a PHIS hospital between July 2009 and June 2019. Subjects were categorized as high risk if they were born prematurely or had a chronic complex condition. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS PICU patients were 26.5% of the 283,006 included subjects but accrued 66% of the total $14.83 billion in charges. Annual charges increased from $1.01 billion in 2009-2010 to $2.07 billion in 2018-2019, and PICU patients accounted for 83% of this increase. PICU + IMV patients were 22% of all PICU patients and accrued 64% of all PICU charges, but PICU - IMV patients without a high-risk condition had the highest relative increase in annual charges, increasing from $76.7 million in 2009-2010 to $377.9 million in 2018-2019 (374% increase, ptrend < 0.001). CONCLUSIONS In a multicenter cohort study of children hospitalized with bronchiolitis, PICU patients, especially low-risk children without the need for IMV, were the highest driver of increased hospital charges over a 10-year study period.
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Affiliation(s)
- Katherine N Slain
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Sindhoosha Malay
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
| | - Steven L Shein
- Department of Pediatrics, Division of Pediatric Critical Care, Rainbow Babies & Children's Hospital, Cleveland, OH
- Case Western Reserve University School of Medicine, Cleveland, OH
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22
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van Stein RM, Lok CA, Aalbers AG, H.J.T. de Hingh I, Houwink AP, Stoevelaar HJ, Sonke GS, van Driel WJ. Standardizing HIPEC and perioperative care for patients with ovarian cancer in the Netherlands using a Delphi-based consensus. Gynecol Oncol Rep 2022; 39:100945. [PMID: 35252523 PMCID: PMC8894234 DOI: 10.1016/j.gore.2022.100945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 02/18/2022] [Accepted: 02/22/2022] [Indexed: 12/29/2022] Open
Abstract
Implementation of HIPEC for ovarian cancer is ongoing, aiming to offer this treatment to all eligible patients in the Netherlands. Standardization reduces unwanted variation in clinical treatment. We intend to standardize patient selection, technical aspects, and perioperative care of CRS and HIPEC. This consensus study comprised a two-phase modified Delphi approach. Consensus was reached on 82% of items.
Objective Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is standard of care in the Netherlands in patients with stage III epithelial ovarian cancer following interval cytoreductive surgery (CRS). Differences in patient selection, technical aspects, and perioperative management exist between centers performing HIPEC. Standardization aims to reduce unwanted variation in clinical practice. As part of an implementation process, we aimed to standardize perioperative care for patients treated with CRS and HIPEC using a Delphi-based consensus approach. Methods We performed a two-phase modified Delphi method involving a multidisciplinary panel of 40 experts who completed a survey on CRS and HIPEC. During a consensus meeting, survey outcomes and available scientific evidence was discussed. Items without consensus (<75% agreement) were adjusted and evaluated in a second survey. Results Consensus was reached in the first round on 51% of items. After two rounds, consensus was reached on the majority of items (82%) including patient selection, preoperative workup, technical aspects of CRS and HIPEC, and postoperative care. No consensus was reached on the role of HIPEC in rare ovarian cancer types, preoperative bowel preparation, timing to create bowel anastomoses, and manipulation of the perfusate. Conclusions Dutch experts reached consensus on most items regarding interval CRS and HIPEC for ovarian cancer. This consensus study may help to align treatment protocols and to minimize practice variation. Topics without consensus may be put on the research agenda of HIPEC for ovarian cancer.
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Bronchiolitis and Noninvasive Ventilation. Once Again Time to Review…. Crit Care Med 2021; 49:2164-2166. [PMID: 34793386 DOI: 10.1097/ccm.0000000000005321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Jansen L, Meyer GP, Curtin G, Lynch B, O'Brien R. Quality improvement project to decrease unnecessary investigations in infants with bronchiolitis in Cork University Hospital. BMJ Open Qual 2021; 10:bmjoq-2021-001428. [PMID: 34782359 PMCID: PMC8593756 DOI: 10.1136/bmjoq-2021-001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 10/25/2021] [Indexed: 11/30/2022] Open
Abstract
Background Bronchiolitis is a common reason for infants to present to the emergency department (ED). Clear evidence-based guidelines exist that recommend against routine radiological and laboratory investigations in this cohort. Despite this, preintervention audit showed that children below 12 months of age with bronchiolitis in the ED during November 2018–January 2019 were receiving unnecessary investigations. Our aim was to improve patient care by decreasing unnecessary investigations in bronchiolitis infants. Methods Baseline assessment comprised a preintervention audit of children less than 12 months of age with a diagnosis of bronchiolitis that presented to ED during November 2018–January 2019. The outcome measure was average weekly hospital length of stay (LOS), process measures were average weekly chest X-ray (CXR) and laboratory investigation rate. The balancing measure was the average weekly representation rate. Intervention A multimodal intervention was implemented comprising a locally agreed flowchart enhanced by regular feedback on performance using run charts and in-person sessions. Results A postintervention audit of November 2019–January 2020 was undertaken. There was a 57% reduction in the mean average weekly CXR rate (from 25% to 11%, p value 0.009974 significant at p<0.05); there was an improvement by 56% in the mean average weekly laboratory investigation rate (from 29% to 13%, p value 0.005475, significant at p<0.05) in the preintervention and postintervention periods, respectively. The mean average weekly representations remained at 4% preintervention and postintervention (p value 0.737). There was no significant difference in hospital LOS (from 25.3 hours to 20.7 hours, p value 0.270549). Conclusion An evidence-based protocol improved physicians’ ability in diagnosing and managing infants with bronchiolitis. This led to a reduction in unnecessary and potential harmful investigations, thereby improving patient quality of care. This improvement will contribute to decreased healthcare cost and appropriate use of resources during the high-pressured winter period.
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Affiliation(s)
- Lizeri Jansen
- Emergency Department, Cork University Hospital, Cork, Ireland .,University of Manchester, Manchester, UK
| | - Gideon-Phil Meyer
- Emergency Department, Cork University Hospital, Cork, Ireland.,University of Manchester, Manchester, UK
| | - Glenn Curtin
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Bryan Lynch
- Emergency Department, Cork University Hospital, Cork, Ireland
| | - Rory O'Brien
- Emergency Department, Cork University Hospital, Cork, Ireland
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Friedman JN, Davis T, Somaskanthan A, Ma A. Avoid doing chest x rays in infants with typical bronchiolitis. BMJ 2021; 375:e064132. [PMID: 34686495 DOI: 10.1136/bmj-2021-064132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Jeremy N Friedman
- Paediatrics, Hospital for Sick Children, Toronto, Ontario M3B 3E8, Canada
| | - Tessa Davis
- Paediatric Emergency Department, Royal London Hospital, London, UK
| | | | - Amy Ma
- Family Advisory Forum, Montreal Children's Hospital, Montreal, Quebec, Canada
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Wolf ER, Richards A, Lavallee M, Sabo RT, Schroeder AR, Schefft M, Krist AH. Patient, Provider, and Health Care System Characteristics Associated With Overuse in Bronchiolitis. Pediatrics 2021; 148:peds.2021-051345. [PMID: 34556548 PMCID: PMC8830481 DOI: 10.1542/peds.2021-051345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15-1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15-1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11-1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.
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Affiliation(s)
- Elizabeth R. Wolf
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia,Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Alicia Richards
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Martin Lavallee
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Roy T. Sabo
- Department of Biostatistics, Virginia Commonwealth University, Richmond, Virginia
| | - Alan R. Schroeder
- Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Matthew Schefft
- Children’s Hospital of Richmond at Virginia Commonwealth University, Richmond, Virginia,Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Alex H. Krist
- Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
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Scanzera AC, Chang AY, Valikodath N, Cole E, Hallak JA, Vajaranant TS, Kim SJ, Chan RVP. Assessment of a novel ophthalmology tele-triage system during the COVID-19 pandemic. BMC Ophthalmol 2021; 21:346. [PMID: 34560849 PMCID: PMC8461141 DOI: 10.1186/s12886-021-02112-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 09/13/2021] [Indexed: 12/29/2022] Open
Abstract
Background In response to the COVID-19 pandemic, a web-based tele-triage system was created to prioritize in-person clinic visits and ensure safety at the University of Illinois at Chicago Department of Ophthalmology and Visual Sciences during a statewide shelter-in-place order. The aim of this study is to evaluate the impact of the tele-triage system on urgent visit volume and explore the characteristics of acute visit requests at a tertiary referral eye center. Methods This retrospective study analyzed acute visit requests between April 6, 2020 and June 6, 2020. Descriptive statistics, chi-square tests, ANOVA, and bivariate logistic regression were used to compare variables with a p-value of 0.05. Results Three hundred fifty-eight surveys were completed. Mean age was 49.7 ± 18.8 years (range 2–91). The majority of requests were determined as urgent (63.0%) or emergent (0.8%). Forty-nine patients had recent eye trauma (13.7%), and the most common reported symptoms were new onset eye pain (25.7%) and photophobia (22.9%). Most patients were self-referred (63.7%), though provider referral was more common in patients with symptoms of new onset lid swelling (p < 0.01), diplopia (p < 0.01), flashing lights (p = 0.02), or droopy eyelid (p < 0.01). Patients presenting with symptom onset within 48 h tended to be younger (45.8 years) versus those with symptom duration of 48 h to 1 week (49.6 years), or more than 1 week (52.6 years; p < 0.01). Conclusion This novel tele-triage system screened out one-third of acute visit requests as non-urgent, which limited in-person visits during the initial shelter-in-place period of the pandemic. Tele-triage systems should be implemented in eye care practices for future emergency preparedness.
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Affiliation(s)
- Angelica C Scanzera
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA.
| | - Arthur Y Chang
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
| | - Nita Valikodath
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
| | - Emily Cole
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
| | - Joelle A Hallak
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
| | - Thasarat Sutabutr Vajaranant
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
| | - Sage J Kim
- Division of Health Policy & Administration, School of Public Health, University of Illinois at Chicago, 1603 W. Taylor Street, Chicago, IL, 60612, USA
| | - R V Paul Chan
- Department of Ophthalmology and Visual Sciences, Illinois Eye and Ear Infirmary, University of Illinois at Chicago, 1855 W. Taylor Street, Chicago, IL, 60612, USA
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Hester G, Nickel AJ, Watson D, Bergmann KR. Factors Associated With Bronchiolitis Guideline Nonadherence at US Children's Hospitals. Hosp Pediatr 2021; 11:1102-1112. [PMID: 34493589 DOI: 10.1542/hpeds.2020-005785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The objective with this study was to explore factors associated with nonadherence to national bronchiolitis guidelines at 52 children's hospitals. METHODS We included patients 1 month to 2 years old with emergency department (ED) or admission encounters between January 2016 and December 2018 and bronchiolitis diagnoses in the Pediatric Health Information System database. We excluded patients with any intensive care, stay >7 days, encounters in the preceding 30 days, chronic medical conditions, croup, pneumonia, or asthma. Guideline nonadherence was defined as receiving any of 5 tests or treatments: bronchodilators, chest radiographs, systemic steroids, antibiotics, and viral testing. Nonadherence outcomes were modeled by using mixed effects logistic regression with random effects for providers and hospitals. Adjusted odds ratio (aOR) >1 indicates greater likelihood of nonadherence. RESULTS A total of 198 028 encounters were included (141 442 ED and 56 586 admission), and nonadherence was 46.1% (ED: 40.2%, admissions: 61.0%). Nonadherence increased with patient age, with both ED and hospital providers being more likely to order tests and treatments for children 12 to 24 months compared with infants 1 ot 2 months (ED: aOR, 3.39; 95% confidence interval [CI], 3.20-3.60; admissions: aOR, 2.97; CI, 2.79-3.17]). Admitted non-Hispanic Black patients were more likely than non-Hispanic white patients to receive guideline nonadherent care (aOR, 1.16; CI, 1.10-1.23), a difference driven by higher use of steroids (aOR, 1.29; CI, 1.17-1.41) and bronchodilators (aOR, 1.39; CI, 1.31-1.48). Hospital effects were prominent for viral testing in ED and admission encounters (intraclass correlation coefficient of 0.35 and 0.32, respectively). CONCLUSIONS Multiple factors are associated with national bronchiolitis guideline nonadherence.
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Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
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Frazier SB, Walls C, Jain S, Plemmons G, Johnson DP. Reducing Chest Radiographs in Bronchiolitis Through High-Reliability Interventions. Pediatrics 2021; 148:peds.2020-014597. [PMID: 34344801 DOI: 10.1542/peds.2020-014597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/08/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Bronchiolitis is a leading cause of pediatric hospitalization in the United States, resulting in significant morbidity and health care resource use. Despite American Academy of Pediatrics recommendations against obtaining chest radiographs (CXRs) for bronchiolitis, variation in care continues. Historically, clinical practice guidelines and educational campaigns have had mixed success in reducing unnecessary CXR use. Our aim was to reduce CXR use for children <2 years with a primary diagnosis of bronchiolitis, regardless of emergency department (ED) disposition or preexisting conditions, from 42.1% to <15% of encounters by March 2020. METHODS A multidisciplinary team was created at our institution in 2012 to standardize bronchiolitis care. Given success with higher reliability interventions in asthma, similar interventions affecting workflow were subsequently pursued with bronchiolitis, starting in 2017, by using quality improvement science methods. The primary outcome was the percent of bronchiolitis encounters with a CXR. The balancing measure was return visits within 72 hours to the ED. Statistical process control charts were used to monitor and analyze data obtained from an internally created dashboard. RESULTS From 2012 to 2020, our hospital had 12 120 bronchiolitis encounters. Preimplementation baseline revealed a mean of 42.1% for CXR use. Low reliability interventions, like educational campaigns, resulted in unsustained effects on CXR use. Higher reliability interventions were associated with sustained reductions to 23.3% and 18.9% over the last 4 years. There was no change in ED return visits. CONCLUSIONS High-reliability workflow redesign was more effective in translating American Academy of Pediatrics recommendations into sustained practice than educational campaigns.
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Affiliation(s)
| | | | | | - Gregory Plemmons
- Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David P Johnson
- Pediatric Hospital Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
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Stephens JR, Hall M, Cotter JM, Molloy MJ, Tchou MJ, Markham JL, Shah SS, Steiner MJ, Aronson PL. Trends and Variation in Length of Stay Among Hospitalized Febrile Infants ≤60 Days Old. Hosp Pediatr 2021; 11:915-926. [PMID: 34385333 DOI: 10.1542/hpeds.2021-005936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Researchers in recent studies suggest that hospitalized febrile infants aged ≤60 days may be safely discharged if bacterial cultures are negative after 24-36 hours of incubation. We aimed to describe trends and variation in length of stay (LOS) for hospitalized febrile infants across children's hospitals. METHODS We conducted a multicenter retrospective cohort study of febrile infants aged ≤60 days hospitalized from 2016 to 2019 at 39 hospitals in the Pediatric Health Information System database. We excluded infants with complex chronic conditions, bacterial infections, lower respiratory tract viral infections, and those who required ICU admission. The primary outcomes were trends in LOS overall and for individual hospitals, adjusted for patient demographics and clinical characteristics. We also evaluated the hospital-level association between LOS and 30-day readmissions. RESULTS We identified 11 868 eligible febrile infant encounters. The adjusted mean LOS for the study cohort decreased from 44.0 hours in 2016 to 41.9 hours in 2019 (P < .001). There was substantial variation in adjusted mean LOS across children's hospitals, range 33.5-77.9 hours in 2016 and 30.4-100.0 hours in 2019. The change from 2016 to 2019 in adjusted mean LOS across individual hospitals also varied widely (-23.9 to +26.7 hours; median change -1.8 hours, interquartile range: -5.4 to 0.3). There was no association between hospital-level LOS and readmission rates (P = .70). CONCLUSIONS The LOS for hospitalized febrile infants decreased marginally between 2016 and 2019, although overall LOS and change in LOS varied substantially across children's hospitals. Continued quality improvement efforts are needed to reduce LOS for hospitalized febrile infants.
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Affiliation(s)
- John R Stephens
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Matt Hall
- Children's Hospital Association, Overland Park, Kansas
| | - Jillian M Cotter
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Matthew J Molloy
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Tchou
- Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | - Jessica L Markham
- Children's Mercy Hospital and University of Missouri-Kansas City, Kansas City, Missouri
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio
| | - Michael J Steiner
- North Carolina Children's Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, School of Medicine, Yale University, New Haven, Connecticut
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Abstract
OBJECTIVES Evaluation of potential benefits of noninvasive ventilation for bronchiolitis has been precluded in part by the absence of large, adequately powered studies. The objectives of this study were to characterize temporal trends in and associations between the use of noninvasive ventilation in bronchiolitis and two clinical outcomes, invasive ventilation, and cardiac arrest. DESIGN Multicenter retrospective cross-sectional study. SETTING Forty-nine U.S. children's hospitals participating in the Pediatric Health Information System database. PATIENTS Infants under 12 months old who were admitted from the emergency department with bronchiolitis between January 1, 2010, and December 31, 2018. MEASUREMENTS AND MAIN RESULTS Primary outcomes were rates of noninvasive ventilation, invasive ventilation, and cardiac arrest. Trends over time were assessed with univariate logistic regression. In the main analysis, hospital-level multivariable logistic regression evaluated rates of outcomes including invasive ventilation and cardiac arrest among hospitals with high and low utilization of noninvasive ventilation. The study included 147,288 hospitalizations of infants with bronchiolitis. Across the entire study population, noninvasive and invasive ventilation increased between 2010 and 2018 (2.9-8.7%, 2.1-4.0%, respectively; p < 0·001). After adjustment for markers of severity of illness, hospital-level noninvasive ventilation (high vs low utilization) was not associated with differences in invasive ventilation (5.0%, 1.8%, respectively, adjusted odds ratio, 1.8; 95% CI, 0·7-4·6) but was associated with increased cardiac arrest (0.36%, 0.02%, respectively, adjusted odds ratio, 25.4; 95% CI, 4.9-131.0). CONCLUSIONS In a large cohort of infants at children's hospitals, noninvasive and invasive ventilation increased significantly from 2010 to 2018. Hospital-level noninvasive ventilation utilization was not associated with a reduction in invasive ventilation but was associated with higher rates of cardiac arrest even after controlling for severity. Noninvasive ventilation in bronchiolitis may incur an unintended higher risk of cardiac arrest, and this requires further investigation.
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Andina Martínez D, Escalada Pellitero S, Viaño Nogueira P, Alonso Cadenas JA, Martín Díaz MJ, de la Torre-Espi M, García RJ. [Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives]. An Pediatr (Barc) 2021; 96:S1695-4033(21)00187-9. [PMID: 34127416 DOI: 10.1016/j.anpedi.2021.05.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/07/2021] [Accepted: 05/05/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6%-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P<.001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P<.001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72h. CONCLUSIONS The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.
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Affiliation(s)
| | | | - Pedro Viaño Nogueira
- Servicio de Pediatría, Hospital Infantil Universitario Niño Jesús, Madrid, España
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Montejo M, Paniagua N, Saiz-Hernando C, Martínez-Indart L, Pijoan JI, Castelo S, Martín V, Benito J. Reducing Unnecessary Treatments for Acute Bronchiolitis Through an Integrated Care Pathway. Pediatrics 2021; 147:peds.2019-4021. [PMID: 33958438 DOI: 10.1542/peds.2019-4021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/08/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To analyze the impact of an integrated care pathway on reducing unnecessary treatments for acute bronchiolitis. METHODS We implemented an evidence-based integrated care pathway in primary care (PC) centers and the referral emergency department (ED). This is the third quality improvement cycle in the management of acute bronchiolitis implemented by our research team. Family and provider experiences were incorporated by using design thinking methodology. A multifaceted plan that included several quality improvement initiatives was adopted to reduce unnecessary treatments. The primary outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were prescribing rates of other medications. The main control measures were hospitalization and unscheduled return rates. Salbutamol prescribing rate data were plotted on run charts. RESULTS We included 1768 ED and 1092 PC visits, of which 913 (51.4%) ED visits and 558 (51.1%) PC visits occurred in the postintervention period. Salbutamol use decreased from 7.7% (interquartile range [IQR] 2.8-21.4) to 0% (IQR 0-1.9) in the ED and from 14.1% (IQR 5.8-21.6) to 5% (IQR 2.7-8) in PC centers. In the ED, the overall epinephrine use rate fell from 9% (95% confidence interval [CI], 7.2-11.1) to 4.6% (95% CI, 3.4-6.1) (P < .001). In PC centers, overall corticosteroid and antibiotic prescribing rates fell from 3.5% (95% CI, 2.2-5.4) to 1.1% (95% CI, 0.4-2.3) (P =.007) and from 9.5% (95% CI; 7.3-12.3) to 1.7% (95% CI, 0.9-7.3) (P <.001), respectively. No significant variations were noted in control measures. CONCLUSIONS An integrated clinical pathway that incorporates the experiences of families and clinicians decreased the use of medications in the management of bronchiolitis.
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Affiliation(s)
| | | | | | | | | | - Susana Castelo
- Innovation and Quality of Care, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Biscay, Basque Country, Spain
| | - Vanesa Martín
- Innovation and Quality of Care, BioCruces Bizkaia Health Research Institute, Cruces University Hospital, Biscay, Basque Country, Spain
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RSV genomic diversity and the development of a globally effective RSV intervention. Vaccine 2021; 39:2811-2820. [PMID: 33895016 DOI: 10.1016/j.vaccine.2021.03.096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 11/23/2022]
Abstract
Respiratory syncytial virus (RSV) is the most common cause of serious lower respiratory tract illness in infants and children and causes significant disease in the elderly and immunocompromised. Recently there has been an acceleration in the development of candidate RSV vaccines, monoclonal antibodies and therapeutics. However, the effects of RSV genomic variability on the implementation of vaccines and therapeutics remain poorly understood. To address this knowledge gap, the National Institute of Allergy and Infectious Diseases and the Fogarty International Center held a workshop to summarize what is known about the global burden and transmission of RSV disease, the phylogeographic dynamics and genomics of the virus, and the networks that exist to improve the understanding of RSV disease. Discussion at the workshop focused on the implications of viral evolution and genomic variability for vaccine and therapeutics development in the context of various immunization strategies. This paper summarizes the meeting, highlights research gaps and future priorities, and outlines what has been achieved since the meeting took place. It concludes with an examination of what the RSV community can learn from our understanding of SARS-CoV-2 genomics and what insights over sixty years of RSV research can offer the rapidly evolving field of COVID-19 vaccines.
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Maki K, Azizi H, Hans P, Doan Q. Adherence to national paediatric bronchiolitis management guidelines and impact on emergency department resource utilization. Paediatr Child Health 2021; 26:108-113. [DOI: 10.1093/pch/pxaa013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/13/2020] [Indexed: 11/13/2022] Open
Abstract
Abstract
Objective
To evaluate the association between the use of nonrecommended pharmacology (salbutamol and corticosteroids) per national bronchiolitis guidelines, either during the index visit or at discharge, and system utilization measures (frequency of return visits [RTED] and on paediatric emergency department [PED] length of stay [LOS]).
Study Design
We conducted a retrospective case control study of 185 infants (≤12 months old) who presented to the PED between December 2014 and April 2017 and discharged home with a clinical diagnosis of bronchiolitis. Inclusion criteria included ≥ 1 viral prodromal symptom and ≥ 1 physical exam finding of respiratory distress. Cases were defined as infants who had ≥ 1 RTED within 7 days of their index visit and controls were matched for age and acuity but without RTED. Logistic regression analysis and multivariable linear regression were used to assess the odds of RTED and PED LOS associated with nonadherence to pharmaceutical recommendations per AAP and CPS bronchiolitis guidelines.
Results
Use of nonrecommended pharmacology per national bronchiolitis guidelines was documented among 39% of the 185 study participants. Adjusting for acuity of index visit, age, severe tachypnea, oxygen desaturation, and dehydration, use of nonrecommended pharmacology was not associated with RTED (odds ratio [OR]: 0.98, 95% confidence interval [CI]: 0.47 to 2.03). Use of salbutamol and corticosteroids, however, were each independently associated with increased PED LOS (58.3 minutes [P=0.01] and 116.7 minutes [P<0.001], respectively).
Conclusion
Nonadherence to the pharmaceutical recommendations of national bronchiolitis guidelines was not associated with RTED but salbutamol and corticosteroid use increased PED LOS.
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Affiliation(s)
- Kate Maki
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
| | - Hawmid Azizi
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Prabhjas Hans
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
| | - Quynh Doan
- Department of Pediatrics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia
- BC Children’s Hospital Research Institute, Vancouver, British Columbia
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Buendía JA, Patiño DG. Costs of Respiratory Syncytial Virus Hospitalizations in Colombia. PHARMACOECONOMICS - OPEN 2021; 5:71-76. [PMID: 32418086 PMCID: PMC7895874 DOI: 10.1007/s41669-020-00218-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Several clinical practice guidelines exist for the management of respiratory syncytial virus (RSV) infection, but the use and overuse of medications and medical tests with insufficient evidence of effectiveness remains substantial. OBJECTIVE This study aimed to evaluate the medical costs associated with bronchiolitis hospitalizations caused by RSV infection among infants aged < 2 years in Colombia. METHODS This was a prevalence-based cost-of-illness multicentric study performed from the societal perspective during 2016-2017. A case was defined as a laboratory-confirmed RSV infection with hospitalization. All costs and use of resources were collected directly from medical invoices and health records. RESULTS This study included 193 patients with a diagnosis of RSV. The average hospital stay duration was 5.55 days. The major contributors to hospitalization costs were room costs (31.5%), drugs (21.8%), and indirect costs (14.9%). Medications with the highest costs were nebulization with a hypertonic solution and systemic antibiotics. In total, 96% of β-lactam antibiotics, 90% of bronchodilators, and 86% of corticosteroids and epinephrine were classified as inappropriate. CONCLUSION RSV infection in Colombia places a high economic burden on the health system. Generating comprehensive data on healthcare resource use and costs associated with RSV will help to provide valuable information for the development of cost-effectiveness models and to guide RSV-prevention strategies.
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Affiliation(s)
- Jefferson Antonio Buendía
- Department of Pharmacology and Toxicology, Research Group in Pharmacology and Toxicology (INFARTO), Centro de Información y Estudio de Medicamentos y Tóxicos (CIEMTO), Faculty of Medicine, Universidad de Antioquia, Carrera 51D #62-29, Medellín, Colombia
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Montejo M, Paniagua N, Saiz-Hernando C, Martinez-Indart L, Mintegi S, Benito J. Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care. Arch Dis Child 2021; 106:294-300. [PMID: 31666241 DOI: 10.1136/archdischild-2019-318085] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 10/09/2019] [Accepted: 10/16/2019] [Indexed: 11/04/2022]
Abstract
We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved two seasons: 2016-2017 (preintervention) and 2017-2018 (postintervention). We distributed an evidence-based protocol, informative posters and badges with the slogan 'Bronchiolitis, less is more'. We also held interactive sessions, and paediatricians received weekly reports on bronchodilator prescription. The main outcome was the percentage of infants prescribed salbutamol. Secondary outcomes were epinephrine, antibiotic and corticosteroid prescription rates. Control measures were ED visit and hospitalisation rates, triage level, length of stay, intensive care admission and unscheduled returns with admission. We included 1878 ED and 1192 PC visits of which 855 (44.5%) and 534 (44.7%) occurred in the postintervention period, respectively. In the ED, salbutamol and epinephrine prescription rates fell from 13.8% (95% CI 11.8% to 16%) to 9.1% (95% CI 7.3% to 11.2%) (p<0.01) and 10.4% (95% CI 8.6% to 12.4%) to 9% (95% CI 7.2% to 11.1%) (n.s.), respectively. In PC, salbutamol, corticosteroid and antibiotic prescription rates fell from 38.3% (95% CI 34.6% to 42.0%) to 15.9% (95% CI 12.9% to 19.5%) (p<0.01), 12.9% (95% CI 10.5% to 15.7%) to 3.6% (95% CI 2.2% to 5.7%) (p<0.01) and 29.6% (95% CI 26.2% to 33.2%) to 9.5% (95% CI 7.2% to 12.5%) (p<0.01), respectively. No significant variations were noted in control measures. We safely decreased the use of unnecessary treatments for AB. Collaboration between PC and ED appears to be an important factor for success.
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Affiliation(s)
- Marta Montejo
- Rontegi-Barakaldo Primary Care Center, University of the Basque Country, Bilbao, Spain
| | - Natalia Paniagua
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain
| | | | | | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Bilbao, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
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House SA, Marin JR, Hall M, Ralston SL. Trends Over Time in Use of Nonrecommended Tests and Treatments Since Publication of the American Academy of Pediatrics Bronchiolitis Guideline. JAMA Netw Open 2021; 4:e2037356. [PMID: 33587138 PMCID: PMC7885040 DOI: 10.1001/jamanetworkopen.2020.37356] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Acute viral bronchiolitis is a common and costly pediatric condition for which clinical practice guidelines discourage use of diagnostic tests and therapies. OBJECTIVE To evaluate trends over time for use of nonrecommended services for bronchiolitis since publication of the American Academy of Pediatrics clinical practice guideline on bronchiolitis (originally published in October 2006 and updated in November 2014). DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted using interrupted time-series regression analysis adjusting for the hospital providing service, patient demographic characteristics, and payer, with 2014 guideline update publication as the event point. Included patients were children younger than 2 years old discharged from the emergency department (ED) or hospital inpatient setting with a primary diagnosis of bronchiolitis at US Children's Hospitals contributing data to the Pediatric Health Information Systems database. Data were analyzed from June through December 2020. MAIN OUTCOMES AND MEASURES Rates of nonrecommended tests (ie, chest radiography, viral testing, and complete blood cell count) and treatments (ie, bronchodilators, corticosteroids, antibiotics) were measured. RESULTS Among 602 375 encounters involving children with a primary diagnosis of bronchiolitis, 404 203 encounters (67.1%) were ED discharges and 198 172 encounters (32.9%) were inpatient discharges; 468 226 encounters (77.7%) involved children younger than 12 months, and 356 796 encounters (59.2%) involved boys. In the period after initial guideline publication (ie, November 2006 to November 2014), a negative use trajectory was found in all measures except viral testing in the ED group. Using the 2014 guideline update as the event point, several measures showed decreased use between study time periods. The greatest decrease was in bronchodilator use, which changed by -13.5 percentage points in the ED group (95% CI, -15.2 percentage points to -11.8 percentage points) and -11.3 percentage points in the inpatient group (95% CI, -13.1 percentage points to -9.4 percentage points). In the period after the 2014 guideline update (ie, December 2014 to December 2019), bronchodilators also showed the greatest change in usage trajectory, steepening more than 2-fold in both groups. In the ED group, the negative trajectory steepened from -0.11% monthly (95% CI, -0.13% to -0.09%) in the first guideline period to a new mean monthly slope of -0.26% (95% CI, -0.30% to -0.23%). In the inpatient group, the mean monthly slope steepened from -0.08% (95% CI, -0.10 to -0.05%) to -0.26% (95% CI, 0.30% to -0.22%). Length of stay decreased from 2.0 days (95% CI, 1.9 days to 2.1 days) to 1.7 days (95% CI, 1.7 days to 1.8 days). Hospital admission rate decreased from 18.0% (95% CI, 13.8% to 22.2%) to 17.8% (95% CI, 13.6 to 22.1%). CONCLUSIONS AND RELEVANCE This cohort study with interrupted time-series analysis found that use of most nonrecommended bronchiolitis services decreased continuously after 2006. The rate of decline in bronchodilator use increased more than 2-fold after the 2014 guideline update. These findings support potential associations of practice guidelines with improved bronchiolitis care.
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Affiliation(s)
- Samantha A. House
- Department of Pediatrics, Children’s Hospital at Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
- Department of Pediatrics, Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | | | | | - Shawn L. Ralston
- Department of Pediatrics, Johns Hopkins Medical School, Baltimore, Maryland
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Campbell A, Hartling L, Louie-Poon S, Scott SD. Parent Experiences Caring for a Child With Bronchiolitis: A Qualitative Study. J Patient Exp 2021; 7:1362-1368. [PMID: 33457588 PMCID: PMC7786786 DOI: 10.1177/2374373520924526] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: Bronchiolitis is an acute lower respiratory infection, with significant impacts on children and families and strains on the health care system. Understanding parents’ experiences and information needs caring for a child with bronchiolitis is crucial to highlight misconceptions or issues contributing to the high burden. The objective of this qualitative study was to describe parents’ experiences caring for a child with bronchiolitis. Methods: Qualitative description guided this study. Participants were recruited from the Stollery Children’s Hospital emergency department (ED), a specialized pediatric ED in a major Canadian urban center. Semi-structured interviews were conducted with 15 parents. Results: Five major themes were identified: (a) their children’s symptoms and behaviors, (b) bronchiolitis affects the entire family, (c) factors influencing parent’s decision to go to ED, (d) ED experience for parents and their children, and (e) bronchiolitis treatment and management. Interviews revealed bronchiolitis has significant effects on both children and families and parents are generally unaware of bronchiolitis symptoms, treatment, and management. Conclusions: Our study highlights that parents have knowledge deficits when it comes to recognizing the presence and severity of bronchiolitis symptoms. Parents would benefit from having more evidence-based resources to enhance their knowledge about the nature of bronchiolitis.
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Affiliation(s)
| | - Lisa Hartling
- Department of Pediatrics, University of Alberta, Edmonton, Canada
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40
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Buendía JA, Rodríguez CA. A predictive model of inappropriate use of medical tests and medications in Bronchiolitis. Pan Afr Med J 2021; 37:94. [PMID: 33425127 PMCID: PMC7757321 DOI: 10.11604/pamj.2020.37.94.22712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 04/18/2020] [Indexed: 11/11/2022] Open
Abstract
Few studies have identified predictors of inappropriate use of medications and medical tests in bronchiolitis. This study aimed to look for potential factors associated with the inappropriate use of medications and tests in bronchiolitis. A retrospective study that included all infants under two years of age in tertiary center admitted due to Bronchiolitis from January 2015 to December 2018. We defined a composite score as the main outcome variable. 1930 patients were included. The most prescribed medications were nebulized hypertonic saline in 1789 patients (92.6%), albuterol (56%), and β-lactam antibiotics (26.4%). The medical tests more commonly ordered were hemogram (95.9%), chest X-rays (92.2%) and C-reactive protein (79.8%). After controlling for potential confounders, it was found that the length of hospital stay increases the risk of the inappropriate use of medications and tests (OR 1.29; CI 95% 1.01-1.65), whereas fever (OR 0.22; CI 95% 0.06-0.71) and leukocytosis (> 15,000/μL) (OR 0.09; CI 95% 0.03-0.32) at admission decrease the risk of the inappropriate use of medications and tests. Inappropriate use of diagnostic tests and drugs for bronchiolitis was a highly prevalent outcome in our population. Patients with longer hospitalizations, absence of fever and a normal white blood cell count at admission, were at increased risk of inappropriate use of medications and medical tests.
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Affiliation(s)
- Jefferson Antonio Buendía
- Grupo de Investigación en Farmacología y Toxicología (INFARTO), Universidad de Antioquia, Medellín, Colombia.,Department of Pharmacology and Toxicology, School of Medicine, University of Antioquia, Medellin, Colombia.,CIEMTO [drug and poison research and information center] at Integrated Laboratory of Specialized Medicine (LIME), Facultad de Medicina-IPS Universitaria, Universidad de Antioquia, Calle 64 #51-31, 050010, Medellin, Colombia
| | - Carlos Andrés Rodríguez
- Grupo de Investigación en Farmacología y Toxicología (INFARTO), Universidad de Antioquia, Medellín, Colombia.,Department of Pharmacology and Toxicology, School of Medicine, University of Antioquia, Medellin, Colombia.,CIEMTO [drug and poison research and information center] at Integrated Laboratory of Specialized Medicine (LIME), Facultad de Medicina-IPS Universitaria, Universidad de Antioquia, Calle 64 #51-31, 050010, Medellin, Colombia
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41
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Andrews C, L Maxwell S, Kerns E, McCulloh R, Alverson B. The Association of Seasonality With Resource Use in a Large National Cohort of Infants With Bronchiolitis. Hosp Pediatr 2021; 11:126-134. [PMID: 33436417 DOI: 10.1542/hpeds.2020-0120] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Examine the degree of seasonal variation in nonrecommended resource use for bronchiolitis management subsequent to publication of the American Academy of Pediatrics (AAP) 2014 guidelines. METHODS We performed a multicenter retrospective cohort study using the Pediatric Health Information System database, examining patients aged 1 to 24 months, diagnosed with bronchiolitis between November 2015 and November 2018. Exclusions included presence of a complex chronic condition, admission to the PICU, hospital stay >10 days, or readmission. Primary outcomes were use rates of viral testing, complete blood count, blood culture, chest radiography, antibiotics, albuterol, and systemic steroids. Each hospital's monthly bronchiolitis census was aggregated into hospital bronchiolitis census quartiles. Mixed-effect logistic regression was performed, comparing the primary outcomes between bronchiolitis census quartiles, adjusting for patient age, race, insurance, hospitalization status, bacterial coinfection, time since publication of latest AAP bronchiolitis guidelines, and clustering by site. RESULTS In total, 196 902 bronchiolitis patient encounters across 50 US hospitals were analyzed. All hospitals followed a similar census pattern, with peaks during winter months and nadirs during summer months. Chest radiography, albuterol, and systemic steroid use were found to significantly increase in lower bronchiolitis census quartiles, whereas rates of viral testing significantly decreased. No significant variation was found for complete blood count testing, blood culture testing, or antibiotic use. Overall adherence with AAP guidelines increased over time. CONCLUSIONS Resource use for patients with bronchiolitis varied significantly across hospital bronchiolitis census quartiles despite adjusting for potential known confounders. There remains a need for greater standardization of bronchiolitis management.
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Affiliation(s)
- Christine Andrews
- Hasbro Children's Hospital and Alpert Medical School, Brown University, Providence, Rhode Island;
| | - Sarah L Maxwell
- Department of Pediatrics, University of California, San Francisco and UCSF Benioff Children's Hospital, San Francisco, California; and
| | - Ellen Kerns
- Children's Hospital and Medical Center Omaha and University of Nebraska Medical Center, Omaha, Nebraska
| | - Russell McCulloh
- Children's Hospital and Medical Center Omaha and University of Nebraska Medical Center, Omaha, Nebraska
| | - Brian Alverson
- Hasbro Children's Hospital and Alpert Medical School, Brown University, Providence, Rhode Island
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Rodriguez-Martinez CE, Nino G, Castro-Rodriguez JA, Perez GF, Sossa-Briceño MP, Buendia JA. Cost-effectiveness analysis of phenotypic-guided versus guidelines-guided bronchodilator therapy in viral bronchiolitis. Pediatr Pulmonol 2021; 56:187-195. [PMID: 33049126 PMCID: PMC8850934 DOI: 10.1002/ppul.25114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 10/09/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. METHODS A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department. RESULTS Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US$184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315-0.8356 vs. 0.7638; 95% UI: 0.7062-0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.
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Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Jose A Castro-Rodriguez
- Division of Pediatrics, Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Geovanny F Perez
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Oishei Children's Hospital, University at Buffalo, Buffalo, New York, USA
| | | | - Jefferson A Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
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Porter P, Brisbane J, Tan J, Bear N, Choveaux J, Della P, Abeyratne U. Diagnostic Errors Are Common in Acute Pediatric Respiratory Disease: A Prospective, Single-Blinded Multicenter Diagnostic Accuracy Study in Australian Emergency Departments. Front Pediatr 2021; 9:736018. [PMID: 34869099 PMCID: PMC8637207 DOI: 10.3389/fped.2021.736018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Accepted: 10/14/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Diagnostic errors are a global health priority and a common cause of preventable harm. There is limited data available for the prevalence of misdiagnosis in pediatric acute-care settings. Respiratory illnesses, which are particularly challenging to diagnose, are the most frequent reason for presentation to pediatric emergency departments. Objective: To evaluate the diagnostic accuracy of emergency department clinicians in diagnosing acute childhood respiratory diseases, as compared with expert panel consensus (reference standard). Methods: Prospective, multicenter, single-blinded, diagnostic accuracy study in two well-resourced pediatric emergency departments in a large Australian city. Between September 2016 and August 2018, a convenience sample of children aged 29 days to 12 years who presented with respiratory symptoms was enrolled. The emergency department discharge diagnoses were reported by clinicians based upon standard clinical diagnostic definitions. These diagnoses were compared against consensus diagnoses given by an expert panel of pediatric specialists using standardized disease definitions after they reviewed all medical records. Results: For 620 participants, the sensitivity and specificity (%, [95% CI]) of the emergency department compared with the expert panel diagnoses were generally poor: isolated upper respiratory tract disease (64.9 [54.6, 74.4], 91.0 [88.2, 93.3]), croup (76.8 [66.2, 85.4], 97.9 [96.2, 98.9]), lower respiratory tract disease (86.6 [83.1, 89.6], 92.9 [87.6, 96.4]), bronchiolitis (66.9 [58.6, 74.5], 94.3 [80.8, 99.3]), asthma/reactive airway disease (91.0 [85.8, 94.8], 93.0 [90.1, 95.3]), clinical pneumonia (63·9 [50.6, 75·8], 95·0 [92·8, 96·7]), focal (consolidative) pneumonia (54·8 [38·7, 70·2], 86.2 [79.3, 91.5]). Only 59% of chest x-rays with consolidation were correctly identified. Between 6.9 and 14.5% of children were inappropriately prescribed based on their eventual diagnosis. Conclusion: In well-resourced emergency departments, we have identified a previously unrecognized high diagnostic error rate for acute childhood respiratory disorders, particularly in pneumonia and bronchiolitis. These errors lead to the potential of avoidable harm and the administration of inappropriate treatment.
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Affiliation(s)
- Paul Porter
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia.,PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia.,School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Joanna Brisbane
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia.,PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia
| | - Jamie Tan
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia
| | - Natasha Bear
- Institute of Health Research, University of Notre Dame, Fremantle, WA, Australia
| | - Jennifer Choveaux
- Department of Paediatrics, Joondalup Health Campus, Joondalup, WA, Australia.,PHI Research Group, Joondalup Health Campus, Joondalup, WA, Australia
| | - Phillip Della
- School of Nursing, Midwifery and Paramedicine, Curtin University, Bentley, WA, Australia
| | - Udantha Abeyratne
- School of Information Technology and Electrical Engineering, University of Queensland, Brisbane, QLD, Australia
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McCulloh RJ, Commers T, Williams DD, Michael J, Mann K, Newland JG. Effect of Combined Clinical Practice Guideline and Electronic Order Set Implementation on Febrile Infant Evaluation and Management. Pediatr Emerg Care 2021; 37:e25-e31. [PMID: 32221058 DOI: 10.1097/pec.0000000000002012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Management of febrile infants 60 days and younger for suspected serious infection varies widely. Clinical practice guidelines (CPGs) are intended to improve clinician adherence to evidence-based practices. In 2011, a CPG for managing febrile infants was implemented in an urban children's hospital with simultaneous release of an electronic order set and algorithm to guide clinician decisions for managing infants for suspected serious bacterial infection. The objective of the present study was to determine the association of CPG implementation with order set use, clinical practices, and clinical outcomes. METHODS Records of febrile infants 60 days and younger from February 1, 2009, to January 31, 2013, were retrospectively reviewed. Clinical documentation, order set use, clinical management practices, and outcomes were compared pre-CPG and post-CPG release. RESULTS In total, 1037 infants pre-CPG and 930 infants post-CPG implementation were identified. After CPG release, more infants 29 to 60 days old underwent lumbar puncture (56% vs 62%, P = 0.02). Overall antibiotic use and duration of antibiotic use decreased for infants 29 to 60 days (57% vs 51%, P = 0.02). Blood culture and urine culture obtainment remained unchanged for older infants. Diagnosed infections, hospital readmissions, and length of stay were unchanged. Electronic order sets were used in 80% of patient encounters. CONCLUSIONS Antibiotic use and lumbar puncture performance modestly changed in accordance with CPG recommendations provided in the electronic order set and algorithm, suggesting that the presence of embedded prompts may affect clinician decision-making. Our results highlight the potential usefulness of these decision aids to improve adherence to CPG recommendations.
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Affiliation(s)
| | | | - David D Williams
- Division of Health Services and Outcomes Research, Children's Mercy Kansas City, Kansas City
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Clinical factors associated with intubation in the high flow nasal cannula era. Am J Emerg Med 2020; 38:2500-2505. [DOI: 10.1016/j.ajem.2019.12.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 12/06/2019] [Accepted: 12/07/2019] [Indexed: 11/17/2022] Open
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Bryan MA, Tyler A, Zhou C, Williams DJ, Johnson DP, Kenyon CC, Haq H, Simon TD, Mangione-Smith R. Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis. Hosp Pediatr 2020; 10:932-940. [PMID: 33106253 DOI: 10.1542/hpeds.2020-0175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis. METHODS We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital. RESULTS We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, P < .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, P < .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, P < .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, P < .01) and documentation of hospital follow-up ($538, P < .05). CONCLUSIONS A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.
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Affiliation(s)
- Mersine A Bryan
- Department of Pediatrics, University of Washington, Seattle, Washington; .,Seattle Children's Research Institute, Seattle, Washington
| | - Amy Tyler
- Section of Hospital Medicine, Department of Pediatrics, School of Medicine, University of Colorado, Aurora, Colorado
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington.,Seattle Children's Research Institute, Seattle, Washington
| | - Derek J Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - David P Johnson
- Division of Hospital Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and Department of Pediatrics, School of Medicine, Vanderbilt University, Nashville, Tennessee
| | - Chén C Kenyon
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia and Department of Pediatrics, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather Haq
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Tamara D Simon
- Division of Hospital Medicine, Children's Hospital of Los Angeles, Los Angeles, California; and
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DePorre AG, Hall M, Puls HT, Daly A, Gay JC, Bettenhausen JL, Markham JL. Variation in Care and Clinical Outcomes Among Infants Hospitalized With Hyperbilirubinemia. Hosp Pediatr 2020; 10:844-850. [PMID: 32917777 DOI: 10.1542/hpeds.2020-0161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To assess hospital-level variation in laboratory testing and intravenous fluid (IVF) use and examine the association between these interventions and hospitalization outcomes among infants admitted with neonatal hyperbilirubinemia. METHODS We performed a retrospective multicenter study of infants aged 2 to 7 days hospitalized with a primary diagnosis of hyperbilirubinemia from December 1, 2016, to June 30, 2018, using the Pediatric Health Information System. Hospital-level variation in laboratory and IVF use was evaluated after adjusting for clinical and demographic factors and associated with hospital-level outcomes by using Pearson correlation. RESULTS We identified 4396 infants hospitalized with hyperbilirubinemia. In addition to bilirubin level, the most frequently ordered laboratories were direct antiglobulin testing (45.7%), reticulocyte count (39.7%), complete blood cell counts (43.7%), ABO blood type (33.4%), and electrolyte panels (12.9%). IVFs were given to 26.3% of children. Extensive variation in laboratory testing and IVF administration was observed across hospitals (all P < .001). Increased use of laboratory testing but not IVFs was associated with a longer length of stay (P = .007 and .162, respectively). Neither supplementary laboratory use nor IVF use was associated with either readmissions or emergency department revisits. CONCLUSIONS Substantial variation exists among hospitals in the management of infants with hyperbilirubinemia. With our results, we suggest that additional testing outside of bilirubin measurement may unnecessarily increase resource use for infants hospitalized with hyperbilirubinemia.
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Affiliation(s)
- Adrienne G DePorre
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri; .,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Matthew Hall
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri.,Children's Hospital Association, Lenexa, Kansas; and
| | - Henry T Puls
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Ashley Daly
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - James C Gay
- Department of Pediatrics, Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jessica L Bettenhausen
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
| | - Jessica L Markham
- Division of Hospital Medicine, Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri.,School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri
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Group-facilitated audit and feedback to improve bronchiolitis care in the emergency department. CAN J EMERG MED 2020; 22:678-686. [DOI: 10.1017/cem.2020.374] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTObjectiveDespite strong evidence recommending supportive care as the mainstay of management for most infants with bronchiolitis, prior studies show that patients still receive low-value care (e.g., respiratory viral testing, salbutamol, chest radiography). Our objective was to decrease low-value care by delivering individual physician reports, in addition to group-facilitated feedback sessions to pediatric emergency physicians.MethodsOur cohort included 3,883 patients ≤ 12 months old who presented to pediatric emergency departments in Calgary, Alberta, with a diagnosis of bronchiolitis from April 1, 2013, to April 30, 2018. Using administrative data, we captured baseline characteristics and therapeutic interventions. Consenting pediatric emergency physicians received two audit and feedback reports, which included their individual data and peer comparators. A multidisciplinary group-facilitated feedback session presented data and identified barriers and enablers of reducing low-value care. The primary outcome was the proportion of patients who received any low-value intervention and was analysed using statistical process control charts.ResultsSeventy-eight percent of emergency physicians consented to receive their audit and feedback reports. Patient characteristics were similar in the baseline and intervention period. Following the baseline physician reports and the group feedback session, low-value care decreased from 42.6% to 27.1% (absolute difference: −15.5%; 95% CI: −19.8% to −11.2%) and 78.9% to 64.4% (absolute difference: −14.5%; 95% CI: −21.9% to −7.2%) in patients who were not admitted and admitted, respectively. Balancing measures, such as intensive care unit admission and emergency department revisit, were unchanged.ConclusionThe combination of audit and feedback and a group-facilitated feedback session reduced low-value care for patients with bronchiolitis.
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Abstract
Bronchiolitis is a common viral illness that affects the lower respiratory tract of infants and young children. The disease is characterized by wheezing and increased mucus production and can range from mild to severe in terms of respiratory distress. This article reviews the epidemiology, clinical presentation, and treatment of bronchiolitis.
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Affiliation(s)
- Lauren Paluch
- At the time this article was written, Lauren Paluch was assistant fellowship director in the urgent care system of Children's Hospital of the King's Daughters in Norfolk, Va. She now is an assistant professor at Eastern Virginia Medical School in Norfolk, Va. The author has disclosed no potential conflicts of interest, financial or otherwise
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Zipursky A, Kuppermann N, Finkelstein Y, Zemek R, Plint AC, Babl FE, Dalziel SR, Freedman SB, Steele DW, Fernandes RM, Florin TA, Stephens D, Kharbanda A, Roland D, Lyttle MD, Johnson DW, Schnadower D, Macias CG, Benito J, Schuh S. International Practice Patterns of Antibiotic Therapy and Laboratory Testing in Bronchiolitis. Pediatrics 2020; 146:peds.2019-3684. [PMID: 32661190 DOI: 10.1542/peds.2019-3684] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/06/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES International patterns of antibiotic use and laboratory testing in bronchiolitis in emergency departments are unknown. Our objective is to evaluate variation in the use of antibiotics and nonindicated tests in infants with bronchiolitis in 38 emergency departments in Pediatric Emergency Research Networks in Canada, the United States, Australia and New Zealand, the United Kingdom and Ireland, and Spain and Portugal. We hypothesized there would be significant variation, adjusted for patient characteristics. METHODS We analyzed a retrospective cohort study of previously healthy infants aged 2 to 12 months with bronchiolitis. Variables examined included network, poor feeding, dehydration, nasal flaring, chest retractions, apnea, saturation, respiratory rate, fever, and suspected bacterial infection. Outcomes included systemic antibiotic administration and urine, blood, or viral testing or chest radiography (CXR). RESULTS In total, 180 of 2359 (7.6%) infants received antibiotics, ranging from 3.5% in the United Kingdom and Ireland to 11.1% in the United States. CXR (adjusted odds ratio [aOR] 2.3; 95% confidence interval 1.6-3.2), apnea (aOR 2.2; 1.1-3.5), and fever (aOR 2.4; 1.7-3.4) were associated with antibiotic use, which did not vary across networks (P = .15). In total, 768 of 2359 infants (32.6%) had ≥1 nonindicated test, ranging from 12.7% in the United Kingdom and Ireland to 50% in Spain and Portugal. Compared to the United Kingdom and Ireland, the aOR (confidence interval) results for testing were Canada 5.75 (2.24-14.76), United States 4.14 (1.70-10.10), Australia and New Zealand 2.25 (0.86-5.74), and Spain and Portugal 3.96 (0.96-16.36). Testing varied across networks (P < .0001) and was associated with suspected bacterial infections (aOR 2.12; 1.30-2.39) and most respiratory distress parameters. Viral testing (591 of 768 [77%]) and CXR (507 of 768 [66%]) were obtained most frequently. CONCLUSIONS The rate of antibiotic use in bronchiolitis was low across networks and was associated with CXR, fever, and apnea. Nonindicated testing was common outside of the United Kingdom and Ireland and varied across networks irrespective of patient characteristics.
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Affiliation(s)
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, School of Medicine, University of California Davis and University of California Davis Health, Sacramento, California
| | - Yaron Finkelstein
- Division of Pediatric Emergency Medicine and.,Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Roger Zemek
- Division of Pediatric Emergency Medicine, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Amy C Plint
- Division of Pediatric Emergency Medicine, Faculty of Medicine, University of Ottawa and Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Franz E Babl
- Emergency Department, Murdoch Children's Research Institute, The Royal Children's Hospital and The University of Melbourne, Melbourne, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital and the Departments of Surgery and Paediatrics: Child and Youth Health, School of Medicine, The University of Auckland, Auckland, New Zealand
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital and
| | - Dale W Steele
- Department of Pediatric Emergency Medicine, Hasbro Children's Hospital and Departments of Emergency Medicine and Pediatrics, Warren Alpert Medical School and Department of Health Services, Policy, and Practice, School of Public Health, Brown University, Providence, Rhode Island
| | - Ricardo M Fernandes
- Department of Pediatrics, Hospital de Santa Maria and Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, Instituto de Medicina Molecular, University of Lisbon, Lisbon, Portugal
| | - Todd A Florin
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University and Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Derek Stephens
- Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Anupam Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospital of Minnesota, Minneapolis, Minnesota
| | - Damian Roland
- Paediatric Emergency Medicine Leicester Academic Group, Children's Emergency Department, Leicester Royal Infirmary, Leicester, United Kingdom.,Social Science Applied to Healthcare Improvement Research Group, Department of Health Sciences, University of Leicester, Leicester, United Kingdom
| | - Mark D Lyttle
- Paediatric Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Faculty of Health and Applied Life Sciences, University of the West of England, Bristol, United Kingdom
| | - David W Johnson
- Departments of Pediatrics, Emergency Medicine, and Physiology and Pharmacology, Alberta Children's Hospital Research Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - David Schnadower
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Charles G Macias
- Division of Pediatric Emergency Medicine, University Hospitals Rainbow Babies and Children's Hospital and Case Western Reserve University, Cleveland, Ohio; and
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Bizkaia, Spain
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine and .,Research Institute, The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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