1
|
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.
Collapse
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
| |
Collapse
|
2
|
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.
Collapse
Affiliation(s)
| | | | | | - Kelly R Bergmann
- Emergency Medicine, Children's Minnesota, Minneapolis, Minnesota
| |
Collapse
|
3
|
Allin E, Nama N, Irvine MA, Pawliuk C, Wright M, Carwana M. Conservative and surgical modalities in the management of paediatric parapneumonic effusion and empyema: a protocol for a living systematic review and network meta-analysis. BMJ Open 2021; 11:e045010. [PMID: 33762243 PMCID: PMC7993311 DOI: 10.1136/bmjopen-2020-045010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Parapneumonic effusion and empyema are common complications of paediatric pneumonia. Acceptable treatment modalities for large parapneumonic effusions include antibiotics alone or in conjunction with surgical interventions. Clear guidelines on the best treatment approach are lacking and mostly based on evidence prior to widespread pneumococcal conjugate 13-valent vaccination (PCV-13). METHODS AND ANALYSIS A living systematic review and network meta-analysis will be performed comparing the five treatment modalities: (1) antibiotics alone; (2) chest tube drainage without fibrinolytics; (3) chest tube drainage with fibrinolytics; (4) video-assisted thoracoscopic surgery and (5) open thoracotomy. The review protocol is reported following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. Eligible studies are randomised controlled trials comparing any pair of interventions in paediatric patients with empyema or parapneumonic effusion. The following databases will be searched: Ovid MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, LILACS and Google Scholar. Citation screening and data extraction will be completed using a validated crowdsourcing methodology using InsightScope. To assess the risk of bias, we will use the revised Cochrane risk of bias tool for randomised trials. The primary outcome of the study is the length of stay. Secondary outcomes are (1) periprocedural complications and (2) need for re-intervention. A frequentist network meta-analysis design will be implemented with a random-effects model comparing different interventions. In a subgroup analysis, studies and patients will be stratified by the size of pleural effusion and the date of trial (pre/post-PCV-13). Eligible citations and available results will be uploaded to an online database, hosted on Open Science Framework. The database will be updated at least every 4 months with any newly published research. ETHICS AND DISSEMINATION No ethics review is required for this study. Results will be published in a peer-reviewed journal. Data will be available as part of an online database summarising the evidence of this living systematic review. PROSPERO REGISTRATION Pending peer review.
Collapse
Affiliation(s)
- Emily Allin
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Nassr Nama
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Michael A Irvine
- Evidence to Innovation, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Colleen Pawliuk
- Evidence to Innovation, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Marie Wright
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Division of Respiratory Medicine, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | - Matthew Carwana
- Faculty of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Evidence to Innovation, British Columbia Children's Hospital Research Institute, Vancouver, British Columbia, Canada
- Division of General Pediatrics, British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
4
|
Kern-Goldberger AS, Hill-Ricciuti AC, Zhou JJ, Savant AP, Rugg L, Dozor AJ, Welter J, Saiman L, Quittell LM. Perceptions of safety monitoring in CF clinical studies and potential impact on future study participation. J Cyst Fibros 2020; 18:530-535. [PMID: 31151855 DOI: 10.1016/j.jcf.2019.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2018] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND Individuals with CF and their parents cite safety concerns as barriers to participating in clinical studies. We assessed whether a brochure/infographic describing patient safety monitoring processes could reduce knowledge and attitude barriers regarding safety monitoring. We also identified factors associated with likely participation in future CF studies. METHODS Respondents from three CF centers in the U.S. were randomly assigned to receive the safety monitoring brochure/infographic or an unrelated brochure. Fifty parents of children with CF <16, 50 adolescents with CF 16-21, and 50 adults with CF ≥22 years old were recruited to complete the study survey. Factors associated with survey responses and with reported likelihood of participating in future studies were assessed. RESULTS Overall the safety monitoring brochure/infographic was associated with increased likelihood of future participation in non-drug studies (aOR 2.30, CI95 1.01-5.28), but not in drug studies. Non-Hispanic respondents reported greater likelihood of participating in a future drug study than Hispanic respondents (aOR 3.18, CI95 1.30-7.74). Adults with CF (aOR 2.62, CI95 1.05-6.51) and parents (aOR 4.49, CI95 1.66-12.15) were more likely than adolescents to report they would ask their care team about clinical trials. Confidence in safety monitoring was associated with reported likelihood of future participation in drug studies. CONCLUSIONS Potential future participation in CF drug and/or non-drug studies was associated with respondent age and ethnicity, receiving the safety monitoring brochure/infographic, and confidence in safety monitoring. Our findings underscore the need for education about safety monitoring, with targeted approaches for the Hispanic CF population and adolescents.
Collapse
Affiliation(s)
| | | | - Juyan J Zhou
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Adrienne P Savant
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Larissa Rugg
- Division of Pulmonary and Sleep Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL 60611, USA
| | - Allen J Dozor
- Division of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - John Welter
- Division of Pediatric Pulmonology, Allergy, Immunology, and Sleep Medicine, New York Medical College and Westchester Medical Center, Valhalla, NY 10595, USA
| | - Lisa Saiman
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Lynne M Quittell
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY 10032, USA.
| |
Collapse
|
5
|
Le Saux NMA, Bowes J, Viel-Thériault I, Thampi N, Blackburn J, Buba M, Harrison MA, Barrowman N. Combined influence of practice guidelines and prospective audit and feedback stewardship on antimicrobial treatment of community-acquired pneumonia and empyema in children: 2012 to 2016. Paediatr Child Health 2020; 26:234-241. [PMID: 34136053 DOI: 10.1093/pch/pxaa066] [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: 11/12/2019] [Accepted: 02/20/2020] [Indexed: 01/15/2023] Open
Abstract
Background Aminopenicillins are recommended empiric therapy for community-acquired pneumonia (CAP). The aim of the study was to assess treatment over a 5-year period after CAP guideline publication and introduction of an antimicrobial stewardship program (ASP). Methods Using ICD-10 discharge codes for pneumonia, children less than 18 years admitted to the Children's Hospital of Eastern Ontario January 1, 2012 and December 31, 2016 were identified. Children ≥ 2 months with consolidation were included. One day of therapy (DOT) was one or more doses of an antimicrobial given for 1 day. Results Of 1,707 patients identified, 713 met inclusion criteria. Eighteen (2.5%) had bacteria identified by culture and 79 of 265 (29.8%) had Mycoplasma pneumoniae detected. Mean DOT/1,000 patient days of aminopenicillins/penicillin (AAP) increased by 18.1% per year (95% confidence interval [CI] -0.2, 39.9%) and decreased by 37.6% per year (95% CI -56.1, -11.3%) for second- and third-generation cephalosporins in the post-ASP period. The duration of discharge antimicrobials decreased. Of 74 (10.4%) patients who had pleural fluid drained, 35 (47.3%) received more than 5 days of AAP and ≤ 5 days of second-/third-generation cephalosporins with no difference in median length of stay nor mean duration of antimicrobials. Conclusions Implementation of CAP management guidelines followed by prospective audit and feedback stewardship was associated with a sustained decrease in the use of broad-spectrum antibiotics in childhood CAP. Use of AAP should also be strongly considered in patients with effusions (even if no pathogen is identified), as clinical outcome appears similar to patients treated with broad-spectrum antimicrobials.
Collapse
Affiliation(s)
- Nicole M A Le Saux
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Jennifer Bowes
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Isabelle Viel-Thériault
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Service d'Infectiologie, Département de Pédiatrie, Centre hospitalier université Laval et Centre mère-enfant Soleil, Québec, Québec
| | - Nisha Thampi
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Julie Blackburn
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario.,Services de microbiologie et de maladies infectieuses, CHU Sainte-Justine, Montréal, Québec
| | - Melanie Buba
- Division of Infectious Diseases, Children's Hospital of Eastern Ontario, Ottawa, Ontario
| | - Mary-Ann Harrison
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| | - Nick Barrowman
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario
| |
Collapse
|
6
|
Vieira SCF, Santos VS, Franco JM, Nascimento-Filho HM, Barbosa KDOESS, Lyra-Junior DPD, Bastos KDA, Cipolotti R, Wayhs MLC, Vieira MC, Solé D, de Morais MB, Gurgel RQ. Brazilian pediatricians' adherence to food allergy guidelines-A cross-sectional study. PLoS One 2020; 15:e0229356. [PMID: 32092100 PMCID: PMC7039437 DOI: 10.1371/journal.pone.0229356] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/04/2020] [Indexed: 12/20/2022] Open
Abstract
Food allergy is an emerging clinical condition in pediatrics, so recommendations on its management have been widely published. Studying pediatricians' adherence to these clinical practice guidelines (CPG) and understanding the reasons for their non-compliance can help to promote better management of this condition. A cross-sectional study was conducted by a survey among Brazilian pediatricians, randomly selected during the 38th Brazilian Congress of Pediatrics, which took place in October, 2017. A validated questionnaire with 16 questions addressing knowledge and practice on food allergy, as well as self-reported adherence to international guidelines was applied. Of the total of 415 pediatricians from all regions of the country who were surveyed, only 69 (16.7%) had a satisfactory adherence rate (≥80%). Adequate adherence to the guidelines was associated with the variables: 'evaluating more than 10 children with suspected cow's milk allergy (CMA) per month'; 'having read the Brazilian consensus'; or 'being aware of any international food allergy guideline'. In 8 of the 10 questions that assessed conscious adherence, a minority of those surveyed (20.3-42.3% variation) stated that they knew that their response was in line with the guidelines. This finding was statistically significant (p<0.05) in 7 of these 8 questions. The self-reported adherence of Brazilian pediatricians to international food allergy guidelines was low. Pediatricians who evaluated a higher number of children with suspected CMA or who were aware of the recommendations, had a higher rate of adherence. The results of the survey found that lack of resource was the major reported barrier to guideline adherence but lack of awareness must be a relevant non perceived barrier. This study shows the pediatricians´ self-reported adherence to food allergy guidelines in a widely overview for the first time in Brazil. More studies are necessary to investigate adherence to guidelines by pediatricians in other countries and to develop strategies to improve adherence.
Collapse
Affiliation(s)
- Sarah Cristina Fontes Vieira
- Graduate Program in Health Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil.,Reference Center for Food Allergy of Sergipe, Federal University of Sergipe, Aracaju, Sergipe, Brazil.,Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| | | | - Jackeline Motta Franco
- Reference Center for Food Allergy of Sergipe, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| | | | | | | | - Kleyton de Andrade Bastos
- Graduate Program in Health Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil.,Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| | - Rosana Cipolotti
- Graduate Program in Health Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil.,Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| | - Mônica Lisboa Chang Wayhs
- Department of Pediatrics, Federal University of Santa Catarina, Florianópolis-Santa Catarina, Brazil
| | - Mário César Vieira
- Center for Pediatric Gastroenterology, Hospital Pequeno Príncipe, Curitiba, Paraná, Brazil.,Department of Pediatrics, Pontifical Catholic University of Paraná, Curitiba, Paraná, Brazil
| | - Dirceu Solé
- Department of Pediatrics, Federal University of São Paulo, São Paulo, São Paulo, Brazil
| | | | - Ricardo Queiroz Gurgel
- Graduate Program in Health Science, Federal University of Sergipe, Aracaju, Sergipe, Brazil.,Department of Medicine, Federal University of Sergipe, Aracaju, Sergipe, Brazil
| |
Collapse
|
7
|
Dunn M, Muthu N, Burlingame CC, Gahman AM, McCloskey M, Tyler LM, Ware EP, Zorc JJ. Reducing Albuterol Use in Children With Bronchiolitis. Pediatrics 2020; 145:peds.2019-0306. [PMID: 31810996 DOI: 10.1542/peds.2019-0306] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In 2014, the American Academy of Pediatrics published bronchiolitis guidelines recommending against the use of bronchodilators. For the winter of 2015 to 2016, we aimed to reduce the proportion of emergency department patients with bronchiolitis receiving albuterol from 43% (previous winter rate) to <35% and from 18% (previous winter rate) to <10% in the inpatient setting. METHODS A team identified key drivers of albuterol use and potential interventions. We implemented changes to our pathway and the associated order set recommending against routine albuterol use and designed education to accompany the pathway changes. We monitored albuterol use through weekly automated data extraction and reported results back to clinicians. We measured admission rate, length of stay, and revisit rate as balancing measures for the intervention. RESULTS The study period included 3834 emergency department visits and 1119 inpatient hospitalizations. In the emergency department, albuterol use in children with bronchiolitis declined from 43% to 20% and was <3 SD control limits established in the previous year, meeting statistical thresholds for special cause variation. Inpatient albuterol use decreased from 18% to 11% of patients, also achieving special cause variation and approaching our goal. The changes in both departments were sustained through the entire bronchiolitis season, and admission rate, length of stay, and revisit rates remained unchanged. CONCLUSIONS Using a multidisciplinary group that redesigned a clinical pathway and order sets for bronchiolitis, we substantially reduced albuterol use at a large children's hospital without impacting other outcome measures.
Collapse
Affiliation(s)
- Michelle Dunn
- Departments of Pediatrics, .,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Naveen Muthu
- Departments of Pediatrics.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Caroline C Burlingame
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | | | | | | | - Eileen P Ware
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - Joseph J Zorc
- Departments of Pediatrics.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|