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Bakkum KE, Stoner KH, Gannon DA, Mike TB, Rajbhandari P. A Quality Improvement Initiative to Reduce Duplicate Inflammatory Marker Use. Pediatr Qual Saf 2024; 9:e769. [PMID: 39301482 PMCID: PMC11412711 DOI: 10.1097/pq9.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 08/25/2024] [Indexed: 09/22/2024] Open
Abstract
Introduction Inflammatory markers (IMs) are often ordered in multiples, even though evidence suggests that this does not add any clinical benefit. The project aimed to reduce the number of duplicate IMs for patients by 10% in 12 months. Methods We implemented a quality improvement (QI) project at our hospital, focusing on patients admitted to the pediatric hospital medicine service. The team chose the model for improvement as the QI methodology. Key interventions included ongoing provider education, integrating the project into the physician incentive plan, and reviewing disease-specific pathways. The primary outcome measure was "duplicate IM use," which was defined as any two or more IMs (procalcitonin, C-reactive protein, or erythrocyte sedimentation rate) obtained on the same patient within 24 hours. The secondary outcome measure was any IM use during their stay, and the balancing measures were average complete blood count use, hospital length of stay, and 7-day readmission rate. Results The baseline duplicate IM use, and any IM use was 43% and 19%, respectively. After the start of this QI project, duplicate IM use decreased to 12%, and the use of any IM also decreased to 12%. Complete blood count use varied from 11% to 24% during the project without obvious correlation to IM use. Hospital length of stay decreased from 2.5 to 2.6 days, and the 7-day readmission rate remained at 2.8%. Conclusions The duplicate IM use and IM use were decreased without a concurrent increase in the balancing measures, indicating that a safe reduction of IM testing is feasible in inpatient pediatric care.
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Affiliation(s)
- Kathryn E Bakkum
- From the Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Kathy H Stoner
- Department of Quality Services, Akron Children's Hospital, Akron, Ohio
| | - David A Gannon
- Lab Administrative Office, Akron Children's Hospital, Akron, Ohio
| | - Thomas B Mike
- From the Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
| | - Prabi Rajbhandari
- From the Division of Hospital Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, Ohio
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Markham JL, Hall M, Shah SS, Burns A, Goldman JL. Antibiotic Diversity Index: A novel metric to assess antibiotic variation among hospitalized children. J Hosp Med 2024. [PMID: 39099133 DOI: 10.1002/jhm.13470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 07/11/2024] [Accepted: 07/14/2024] [Indexed: 08/06/2024]
Abstract
BACKGROUND Despite nationally endorsed treatment guidelines and stewardship programs, variation and deviation from evidence-based antibiotic prescribing occur, contributing to inappropriate use and medication-related adverse events. Measures of antibiotic prescribing variability can aid in quantifying this problem but are not adequate. OBJECTIVE The objective of this study is to develop a standardized metric to quantify antibiotic prescribing variability (diversity) within and across children's hospitals, and to examine its association with outcomes. METHODS We performed a cross-sectional study of empiric antibiotic exposure among children hospitalized during 2017-2019 with one of 15 common pediatric infections using the Pediatric Health Information System database. Encounters for children with complex chronic conditions, transfers in, and birth hospitalizations were excluded. Using the Shannon-Weiner entropy index, we quantified antibiotic diversity for each infection type using the d-measure of diversity. Generalized linear mixed-effects models were used to examine the association between hospital-level antibiotic diversity and risk-adjusted length of stay and costs. RESULTS A total of 79,515 hospitalizations for common pediatric infections were included. Antibiotic diversity varied within and across hospitals. Infections with low mean antibiotic diversity included appendicitis (mean diversity [mDiv] = 4.9, SD = 2.5) and deep neck space infections (mDiv = 5.9, SD = 1.9). Infections with high mean antibiotic diversity included pneumonia (mDiv = 23.4, SD = 5.6) and septicemia/bacteremia (mDiv = 28.5, SD = 12.1). There was no statistically significant association between hospital-level antibiotic diversity and risk-adjusted LOS or costs. CONCLUSIONS We developed and applied a novel metric to quantify diversity in antibiotic prescribing that permits comparisons across hospitals and can be leveraged to identify high-priority areas for local and national stewardship interventions.
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Affiliation(s)
- Jessica L Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S Shah
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Alaina Burns
- Department of Pharmacy, Children's Mercy Kansas City, University of Missouri-Kansas City School of Pharmacy, Kansas City, Missouri, USA
| | - Jennifer L Goldman
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024; 19:671-679. [PMID: 38643414 PMCID: PMC11296890 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A >2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all 10 years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J. Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R. Stephens
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J. Steiner
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S. Shah
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M. Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
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Collins ME, Hall M, Shah SS, Molloy MJ, Aronson PL, Cotter JM, Steiner MJ, McCoy E, Tchou MJ, Stephens JR, Markham JL. Phlebotomy-free days in children hospitalized with common infections and their association with clinical outcomes. J Hosp Med 2024; 19:251-258. [PMID: 38348499 PMCID: PMC11155307 DOI: 10.1002/jhm.13282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 12/08/2023] [Accepted: 01/01/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND Phlebotomy for hospitalized children has consequences (e.g., pain, iatrogenic anemia), and unnecessary testing is a modifiable source of waste in healthcare. Days without blood draws or phlebotomy-free days (PFDs) has the potential to serve as a hospital quality measure. OBJECTIVE To describe: (1) the frequency of PFDs in children hospitalized with common infections and (2) the association of PFDs with clinical outcomes. DESIGN, SETTINGS AND PARTICIPANTS We performed a cross-sectional study of children hospitalized 2018-2019 with common infections at 38 hospitals using the Pediatric Health Information System database. We included infectious All Patients Refined Diagnosis Related Groups with a median length of stay (LOS) >2 days. We excluded patients with medical complexity, interhospital transfers, those receiving intensive care, and in-hospital mortality. MAIN OUTCOME AND MEASURES We defined PFDs as hospital days (midnight to midnight) without laboratory blood testing and measured the proportion of PFDs divided by total hospital LOS (PFD ratio) for each condition and hospital. Higher PFD ratios signify more days without phlebotomy. Hospitals were grouped into low, moderate, and high average PFD ratios. Adjusted outcomes (LOS, costs, and readmissions) were compared across groups. RESULTS We identified 126,135 encounters. Bronchiolitis (0.78) and pneumonia (0.54) had the highest PFD ratios (most PFDs), while osteoarticular infections (0.28) and gastroenteritis (0.30) had the lowest PFD ratios. There were no differences in adjusted clinical outcomes across PFD ratio groups. Among children hospitalized with common infections, PFD ratios varied across conditions and hospitals, with no association with outcomes. Our data suggest overuse of phlebotomy and opportunities to improve the care of hospitalized children.
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Affiliation(s)
- Megan E. Collins
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Matt Hall
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- Children's Hospital Association, Lenexa, Kansas, USA
| | - Samir S. Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jillian M. Cotter
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children's Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Michael J. Tchou
- University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | | | - Jessica L. Markham
- Department of Pediatrics, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
- University of Kansas School of Medicine, Kansas City, Kansas, USA
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Markham JL, Richardson T, Stephens JR, Gay JC, Hall M. Essential Concepts for Reducing Bias in Observational Studies. Hosp Pediatr 2023; 13:e234-e239. [PMID: 37416975 PMCID: PMC10527895 DOI: 10.1542/hpeds.2023-007116] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Randomized controlled trials (RCTs) are the gold standard study design for clinical research, as prospective randomization, at least in theory, balances any differences that can exist between groups (including any differences not measured as part of the study) and isolates the studied treatment effect. Any remaining imbalances after randomization are attributable to chance. However, there are many barriers to conducting RCTs within pediatric populations, including lower disease prevalence, high costs, inadequate funding, and additional regulatory requirements. Researchers thus frequently use observational study designs to address many research questions. Observational studies, whether prospective or retrospective, do not involve randomization and thus have more potential for bias when compared with RCTs because of imbalances that can exist between comparison groups. If these imbalances are associated with both the exposure of interest and the outcome, then failure to account for these imbalances may result in a biased conclusion. Understanding and addressing differences in sociodemographic and/or clinical characteristics within observational studies are thus necessary to reduce bias. Within this Method/ology submission we describe techniques to minimize bias by controlling for important measurable covariates within observational studies and discuss the challenges and opportunities in addressing specific variables.
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Affiliation(s)
- Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri
- Department of Pediatrics, The University of Kansas, Kansas City, Kansas
| | | | - John R. Stephens
- Department of Medicine, North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - James C. Gay
- Department of Pediatrics, Vanderbilt University School of Medicine, Monroe Carrell, Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
| | - Matt Hall
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri Kansas City, Kansas City, Missouri
- Children’s Hospital Association, Lenexa, Kansas
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Stephens JR, Hall M, Molloy MJ, Markham JL, Cotter JM, Tchou MJ, Aronson PL, Steiner MJ, McCoy E, Collins ME, Shah SS. Establishment of achievable benchmarks of care in the neurodiagnostic evaluation of simple febrile seizures. J Hosp Med 2022; 17:327-341. [PMID: 35560723 PMCID: PMC11309806 DOI: 10.1002/jhm.12833] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/02/2022] [Accepted: 03/16/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Current guidelines recommend against neurodiagnostic testing for the evaluation of simple febrile seizures. OBJECTIVES (1) Assess overall and institutional rates of neurodiagnostic testing and (2) establish achievable benchmarks of care (ABCs) for children evaluated for simple febrile seizures at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of children 6 months to 5 years evaluated in the emergency department (ED) 2016-2019 with simple febrile seizures at 38 children's hospitals in Pediatric Health Information System database. We excluded children with epilepsy, complex febrile seizures, complex chronic conditions, and intensive care. OUTCOME MEASURES Proportions of children who received neuroimaging, electroencephalogram (EEG), or lumbar puncture (LP) and rates of hospitalization for study cohort and individual hospitals. Hospital-specific outcomes were adjusted for patient demographics and severity of illness. We utilized hospital-specific values for each measure to calculate ABCs. RESULTS We identified 51,015 encounters. Among the study cohort 821 (1.6%) children had neuroimaging, 554 (1.1%) EEG, 314 (0.6%) LP, and 2023 (4.0%) were hospitalized. Neurodiagnostic testing rates varied across hospitals: neuroimaging 0.4%-6.7%, EEG 0%-8.2%, LP 0%-12.7% in patients <1-year old and 0%-3.1% in patients ≥1 year. Hospitalization rate ranged from 0%-14.5%. Measured outcomes were higher among hospitalized versus ED-only patients: neuroimaging 15.3% versus 1.0%, EEG% 24.7 versus 0.1% (p < .001). Calculated ABCs were 0.6% for neuroimaging, 0.1% EEG, 0% LP, and 1.0% hospitalization. CONCLUSIONS Rates of neurodiagnostic testing and hospitalization for simple febrile seizures were low but varied across hospitals. Calculated ABCs were 0%-1% for all measures, demonstrating that adherence to current guidelines is attainable.
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Affiliation(s)
- John R. Stephens
- Department of Pediatrics, North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Matt Hall
- Children’s Hospital Association, Overland Park, Kansas, USA
| | - Matthew J. Molloy
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Jillian M. Cotter
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Michael J. Tchou
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J. Steiner
- Department of Pediatrics, North Carolina Children’s Hospital, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Pediatrics, Le Bonheur Children’s Hospital, Memphis, Tennessee, USA
| | - Megan E. Collins
- Department of Pediatrics, Children’s Mercy Kansas City, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Samir S. Shah
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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