Implementing a Standardized Clinical Pathway Leads to Reduced Asthma Admissions and Health Care Costs

Analysis of hospitalization expenses and influencing factors for elderly cancer patients in a tertiary hospital in Dalian, China: a five‑year retrospective study

BACKGROUND

Because the proportion of elderly individuals and the incidence of cancer worldwide are continually increasing, medical costs for elderly inpatients with cancer are being significantly increasing, which puts tremendous financial pressure on their families and society. The current study described the actual direct medical costs of elderly inpatients with cancer and analyzed the influencing factors for the costs to provide advice on the prevention and control of the high medical costs of elderly patients with cancer.

METHOD

A retrospective descriptive analysis was performed on the hospitalization expense data of 11,399 elderly inpatients with cancer at a tier-3 hospital in Dalian between June 2016 and June 2020. The differences between different groups were analyzed using univariate analysis, and the influencing factors of hospitalization expenses were explored by multiple linear regression analysis.

RESULTS

The hospitalization cost of elderly cancer patients showed a decreasing trend from 2016 to 2020. Specifically, the top 3 hospitalization costs were material costs, drug costs and surgery costs, which accounted for greater than 10% of all cancers according to the classification: colorectal (23.96%), lung (21.74%), breast (12.34%) and stomach cancer (12.07%). Multiple linear regression analysis indicated that cancer type, surgery, year and length of stay (LOS) had a common impact on the four types of hospitalization costs (P < 0.05).

CONCLUSION

There were significant differences in the four types of hospitalization costs for elderly cancer patients according to the LOS, surgery, year and type of cancer. The study results suggest that the health administration department should enhance the supervision of hospital costs and elderly cancer patient treatment. Measures should be taken by relying on the hospital information system to strengthen the cost management of cancer diseases and departments, optimize the internal management system, shorten elderly cancer patients LOS, and reasonably control the costs of disease diagnosis, treatment and department operation to effectively reduce the economic burden of elderly cancer patients.

Adherence to the asthma pathway, including pre-triage bronchodilator history, reduces hospitalizations

Objective: To determine if adherence to an asthma treatment pathway is associated with a decrease in hospitalizations.Methods: A prospective cohort design was conducted of Thai children aged 2-15 years who visited the emergency department with severe asthma exacerbations, defined as a Buddhasothorn Asthma Severity Score ≥ 8. Patients who received systemic corticosteroids and nebulized short-acting beta-2 agonists combined with ipratropium bromides were classified as the adherence group. The timing of steroid and bronchodilator administration, length of hospital stay, and hospitalization rate were examined in relation to adherence to the asthma pathway. Multivariable logistic regression models and adjusted odds ratios were used to assess associations.Results: A total of 118 episodes of asthma exacerbations (EAEs) from 59 participants were included. Patients who adhered to the pathway had a significantly higher rate of systemic corticosteroid administration within 1 h of arrival at triage (88.6% vs. 41.9%, adjusted Odds Ratio: aOR 10.21; 95%CI 3.52-29.62). A higher proportion of the patients who adhered to the pathway also received inhaled ipratropium bromide ≥ 2 doses within 1 h of arrival at triage (72.7% vs. 12.2%, aOR 23.51; 95%CI 7.73-71.54) and it was administered significantly faster by 31 min (5 min vs. 36 min, p < 0.001) compared to non-adherence group. The hospitalization rate was significantly lower by almost half of EAEs for adherence group (36.4% vs. 63.5%, aOR 0.41; 95%CI 0.18-0.93).Conclusions: Accurate assessment of severity and adherence to the clinical pathway can reduce hospitalization in pediatric patients with severe asthma exacerbations.

A Quality Improvement Initiative to Minimize Unnecessary Chest X-Ray Utilization in Pediatric Asthma Exacerbations

Background

Current national guidelines recommend against chest X-rays (CXRs) for patients with acute asthma exacerbation (AAE). The overuse of CXRs in AAE has become a concern, prompting the need for a quality improvement (QI) project to decrease CXR usage through guideline-based interventions. We aimed to reduce the percentage of CXRs not adhering to national guidelines obtained for pediatric patients presenting to the Emergency Department (ED) with AAE by 50% within 12 months of project initiation.

Methods

We conducted this study at a New York City urban level-2 trauma center. The team was composed of members from the ED and pediatric departments. Electronic medical records of children aged 2 to 18 years presenting with AAE were evaluated. Monthly data on CXR utilization encompassing instances where the ordered CXR did not adhere to guidelines was collected before and after implementing interventions. The interventions included provider education, visual reminders, printed cards, grand-round presentations, and electronic medical records modifications.

Results

The study encompassed 887 eligible patients with isolated AAE. Baseline data revealed a mean preintervention CXR noncompliance rate of 37.5% among children presenting to the ED with AAE. The interventions resulted in a notable decrease in unnecessary CXR utilization, reaching 16.7%, a reduction sustained throughout subsequent months.

Conclusions

This QI project successfully reduced unnecessary CXR utilization in pediatric AAE. A multi-faceted approach involving education, visual aids, and electronic reminders aligned clinical practice with evidence-based guidelines. This QI initiative is a potential template for other healthcare institutions seeking to curtail unnecessary CXR usage in pediatric AAE.

Breathing across ages: a systematic review on challenges and components of transitional care for young people with asthma

Introduction

Asthma is a chronic condition that affects millions of adolescents and young adults (AYA) worldwide. The transition from pediatric to adult care presents unique challenges for this population, affecting their self-management, quality of life and overall health outcomes. This systematic review aims to consolidate the available evidence on challenges encountered by AYA with asthma during the transition period from child to AYA and on the key elements of transitional care for AYAs with asthma including the outcomes achieved, ultimately enhancing outcomes.

Methodology

A systematic literature search was performed in PubMed, Embase, Medline, Scopus, and Web of Science from their inception to October 2, 2023, to provide an overview of currently available literature. Primary quantitative and qualitative studies, published in peer-reviewed journals that focused on AYA with a confirmed diagnosis of asthma were considered if they focused on challenges encountered by AYA with asthma during the transition process and/or components of transitional care and their outcomes assessed.

Results

A total of 855 studies were initially identified and 6 articles were included in this systematic literature review. Several challenges experienced by AYA with asthma were identified including maintaining medication adherence, the need to take responsibility and being involved, understanding their condition and its severity, feeling left out of the care system, and experiencing a lack of engagement. The identified transitional care components included a standardized form for medical data transmission, a joint consultation and to offer several longer consultations.

Conclusion

Several international guidelines for asthma care recommend implementing transition programs in the care for AYA with asthma. Such transition programs should include a comprehensive and individualized approach addressing several challenges faced, to ensure optimal outcomes post-transition. However, to date, data on effective components of transitional care facilitating good outcomes were found to be limited. This systematic review underscores the need for larger studies evaluating the effect of the components of transition programs.

Managing Pediatric Asthma Exacerbations: The Role of Timely Systemic Corticosteroid Administration in Emergency Care Settings-A Multicentric Retrospective Study

BACKGROUND

Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration.

METHODS

This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included.

RESULTS

205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration.

CONCLUSIONS

Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.

Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations

BACKGROUND

Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission.

OBJECTIVE

To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions.

METHODS

Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration.

RESULTS

A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95).

CONCLUSIONS

Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.

Equitable and Timely Care of Febrile Neonates: A Cross-Sectional Study

OBJECTIVES

In pediatric emergency departments (EDs), racial/ethnic minorities are less likely to receive needed and timely care; however, clinical protocols have the potential to mitigate disparities. Neonatal fever management is protocolized in many EDs, but the timeliness to antibiotic administration is likely variable. We investigated the timeliness of antibiotic administration for febrile neonates and whether timeliness was associated with patients' race/ethnicity.

METHODS

Retrospective cross-sectional study of febrile neonates evaluated in one pediatric ED that uses an evidence-based guideline for the management of neonatal fever between March 2010 and December 2015. Primary outcome was time from ED arrival to antibiotic administration. Analysis of variance tests compared mean time with antibiotic administration across race/ethnicity. Multivariable linear regression investigated racial/ethnic differences in time to antibiotic administration after adjusting for patient demographics, timing of visit, the number of physicians involved, and ED census.

RESULTS

We evaluated 317 febrile neonates. Of the 269 patients with racial/ethnic data (84.9%), 54% were white non-Hispanic, 13% were black non-Hispanic, and 23% were Hispanic. The mean time to antibiotic administration was 204 minutes (range = 51-601 minutes). There was no significant association between patient race/ethnicity and time to first antibiotic administration. Emergency department census was significantly associated with timeliness.

CONCLUSIONS

There was a 10-hour range in the time to antibiotic administration for febrile neonates; however, variability in timeliness did not differ by race or ethnicity. This study demonstrates the need to further examine the role of protocols in mitigating disparities as well as factors that influence timeliness in antibiotic administration to febrile neonates.

Impact of a shift in treatment funding on a multidisciplinary sleep clinic: a cohort study

Multidisciplinary Sleep Clinics for sleep apnea have long existed, bringing together neurologists, sleep specialists, dentists, orthodontists and surgeons. In Belgium, a shift in funding for obstructive sleep apnea treatment was implemented from January 1st, 2017. Funding was allowed for moderate to severe obstructive sleep apnea and the rules shifted for treatments delivery and monitoring by authorised medical opinion. We aimed to assess whether a shift in treatment funding was associated with a change in the multidisciplinary sleep practice. Sample consisted of all patients discussed in the sleep multidisciplinary team meetings of the University Hospital of Liege from January 2016 to December 2018. Interrupted times series, Mann-Whitney U tests and descriptive statistics were produced. There were no differences in patients age, male sex preponderance, body mass index, clinical presentation and level of obstruction. Baseline obstructive sleep apnea severity was significantly lower (mean apnea-hypopnea index and mean oxygen desaturation index lowered with p = 0.0189 and p = 0.0466, respectively) after the funding rules changed. Oral appliance and ENT surgery were more often offered after the shift in funding. The key changes of the new funding rules for obstructive sleep apnea were reflected in the patient selection and management by sleep multidisciplinary team meeting. Funding terms could influence the care we give, not only in treatment options, but also in patients selection.

Pediatric asthma pathway in the emergency room

Asthma is one of the leading causes of hospital admission in the pediatric population. Standardization of asthma management guidelines for patients admitted to the emergency department has been suggested to improve care delivery and patient outcomes. Utilizing a multidisciplinary asthma task force at a single academic medical center, we sought to determine if a protocol-driven approach to implementation of care for patients with asthma could improve patient outcomes by reducing wait times for administration of steroids. A prospective cohort study examined the use of a standardized asthma pathway over a 2-year period compared to historical controls. Pathway use significantly decreased time to corticosteroid administration (45 vs. 29 min [year 1] and 20 min [year 2]; P < 0.0001). By implementing this standard of care at pediatric emergency departments, time to treatment can be decreased, therefore improving the morbidity and mortality of pediatric patients with asthma nationwide.