Recognizing Differences in Hospital Quality Performance for Pediatric Inpatient Care

A National Quality Improvement Collaborative to Improve Antibiotic Use in Pediatric Infections

BACKGROUND

Nearly 25% of antibiotics prescribed to children are inappropriate or unnecessary, subjecting patients to avoidable adverse medication effects and cost.

METHODS

We conducted a quality improvement initiative across 118 hospitals participating in the American Academy of Pediatrics Value in Inpatient Pediatrics Network 2020 to 2022. We aimed to increase the proportion of children receiving appropriate: (1) empirical, (2) definitive, and (3) duration of antibiotic therapy for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infections to ≥85% by Jan 1, 2022. Sites reviewed encounters of children >60 days old evaluated in the emergency department or hospital. Interventions included monthly audit with feedback, educational webinars, peer coaching, order sets, and a mobile app containing site-specific, antibiogram-based treatment recommendations. Sites submitted 18 months of baseline, 2-months washout, and 10 months intervention data. We performed interrupted time series (analyses for each measure.

RESULTS

Sites reviewed 43 916 encounters (30 799 preintervention, 13 117 post). Overall median [interquartile range] adherence to empirical, definitive, and duration of antibiotic therapy was 67% [65% to 70%]; 74% [72% to 75%] and 61% [58% to 65%], respectively at baseline and was 72% [71% to 72%]; 79% [79% to 80%] and 71% [69% to 73%], respectively, during the intervention period. Interrupted time series revealed a 13% (95% confidence interval: 1% to 26%) intercept change at intervention for empirical therapy and a 1.1% (95% confidence interval: 0.4% to 1.9%) monthly increase in adherence per month for antibiotic duration above baseline rates. Balancing measures of care escalation and revisit or readmission did not increase.

CONCLUSIONS

This multisite collaborative increased appropriate antibiotic use for community-acquired pneumonia, skin and soft tissue infections, and urinary tract infection among diverse hospitals.

Hospital Volumes of Inpatient Pediatric Surgery in the United States

BACKGROUND

Perioperative outcomes of children depend on the skill and expertise in managing pediatric patients, as well as integration of surgical, anesthesiology, and medical teams. We compared the types of pediatric patients and inpatient surgical procedures performed in low- versus higher-volume hospitals throughout the United States.

METHODS

Retrospective analysis of 323,258 hospitalizations with an operation for children age 0 to 17 years in 2857 hospitals included in the Agency for Healthcare Research and Quality (AHRQ) Kids' Inpatient Database (KID) 2016. Hospitals were categorized by their volume of annual inpatient surgical procedures. Specific surgeries were distinguished with the AHRQ Clinical Classification System. We assessed complex chronic conditions (CCCs) using Feudtner and Colleagues' system.

RESULTS

The median annual volume of pediatric inpatient surgeries across US hospitals was 8 (interquartile range [IQR], 3-29). The median volume of inpatient surgeries for children with a CCC was 4 (IQR, 1-13). Low-volume hospitals performed significantly fewer types of surgeries (median 2 vs 131 types of surgeries in hospitals with 1-24 vs ≥2000 volumes). Appendectomy and fixation of bone fracture were among the most common surgeries in low-volume hospitals. As the volume of surgical procedures increased from 1 to 24 to ≥2000, the percentage of older children ages 11 to 17 years decreased (70.9%-32.0% [P < .001]) and the percentage of children with a CCC increased (11.2%-60.0% [P < .001]).

CONCLUSIONS

Thousands of US hospitals performed inpatient surgeries on few pediatric patients, including those with CCCs who have the highest risk of perioperative morbidity and mortality. Evaluation of perioperative decision making, workflows, and pediatric clinicians in low- and higher-volume hospitals is warranted.

Process Metrics and Outcomes to Inform Quality Improvement in Pediatric Hospital Medicine

This article provides an overview of the selection, development, and use of process and outcome measures for pediatric hospital medicine quality improvement initiatives. It reviews commonly used categories of process and outcome measures and provides a list of common sources and repositories of previously validated measures. It also provides a blueprint for the development of novel measures. The relative merits of various data collection methods are discussed (eg, medical record abstraction, administrative, surveys), along with guiding principles for disseminating the results of quality improvement evaluations on a local and national level.

Pediatric Quality Metrics Related to Quality and Cost

The institution of pediatric quality in health care has grown in the past decade but continues to evolve. Children's health care emphasizes the importance of maintenance of health and prevention of illness, which can be measured based on immunization rates, routine or scheduled well care, and early intervention. Pediatric quality measures and indicators have become the basis for payment of services and a true goal to value. Designing processes such as pay-for-performance models, volume-based care, and coordination of care assist in assuring that children receive high-quality health care.

Pediatric Inpatient-Status Volume and Cost at Children's and Nonchildren's Hospitals in the United States: 2000-2009

OBJECTIVES

The evolving role of children's hospitals (CHs) in the setting of rising health care costs has not been fully explored. We compared pediatric inpatient discharge volumes and costs by hospital type and examined the impact of care complexity and hospital-level factors on costs.

METHODS

A retrospective, cross-sectional study of care between 2000 and 2009 was performed by using the Kids' Inpatient Database. Weighted discharge data were used to generate national estimates for a comparison of inpatient volume, cost, and complexity at CHs and nonchildren's hospitals (NCHs). Linear regression was used to assess how complexity, payer mix, and hospital-level characteristics affected inflation-adjusted costs.

RESULTS

Between 2000 and 2009, the number of discharges per 1000 children increased from 6.3 to 7.7 at CHs and dropped from 55.4 to 53.3 at NCHs. The proportion of discharges at CHs grew by 6.8% between 2006 and 2009 alone. In 2009, CHs were responsible for 12.6% (95% confidence interval: 10.4%-14.9%) of pediatric discharges and 14.7% of major therapeutic procedures, yet they accounted for 23.0% of inpatient costs. Costs per discharge were significantly higher at CHs than at NCHs for all years (P < .001); however, the increase in costs seen over time was not significant. Care complexity increased during the study period at both CHs and NCH, but it could not be used to fully account for the difference in costs.

CONCLUSIONS

National trends reveal a small rise in both the proportion of inpatient discharges and the hospital costs at CHs, with costs being significantly higher at CHs than at NCHs. Research into factors influencing costs and the role of CHs is needed to inform policy and contain costs.

Should Emergency Department Attendances be Used With or Instead of Readmission Rates as a Performance Metric?: Comparison of Statistical Properties Using National Data

BACKGROUND

Hospital readmissions are common and are viewed as unfavorable. They are commonly used as a measure of quality of care and, in the United States and England, are associated with financial penalties. Readmissions are not the only possible return-to-acute-care metric; patients may also attend emergency departments (EDs).

OBJECTIVE

To assess hospital-level return-to-acute-care metrics using statistical criteria.

RESEARCH DESIGN

Patient readmissions and/or ED attendances were aggregated to produce risk-standardized hospital rates. Return-to-acute-care rates at 7, 30, 90, and 365 days were assessed using key statistical properties: (i) variability between hospitals; (ii) the relative contribution of patient and nonpatient factors to variation; and (iii) the statistical power to detect performance differences.

SUBJECTS

We had pseudonymized administrative data on all inpatient hospital admissions and ED attendances in National Health Service hospitals in England between April 2009 and March 2011. Patients with an inpatient stay for chronic obstructive pulmonary disorder or heart failure were eligible for inclusion.

MEASURES

ED attendances and readmissions for patients discharged from an inpatient stay for chronic obstructive pulmonary disorder or heart failure.

RESULTS

Interhospital variation was greatest for ED attendance; in addition, readmission was more strongly determined by patient characteristics than was ED attendance or both combined. Because of smaller numbers, the statistical power to detect differences in rates at 7 days for any indicator was limited.

CONCLUSIONS

Despite the current emphasis on readmissions, we found that ED attendance within 30 days has more desirable statistical properties and therefore the potential to be a useful metric when comparing hospitals.

Pediatric Price Transparency: Still Opaque With Opportunities for Improvement

OBJECTIVES

Price transparency is gaining importance as families' portion of health care costs rise. We describe (1) online price transparency data for pediatric care on children's hospital Web sites and state-based price transparency Web sites, and (2) the consumer experience of obtaining an out-of-pocket estimate from children's hospitals for a common procedure.

METHODS

From 2015 to 2016, we audited 45 children's hospital Web sites and 38 state-based price transparency Web sites, describing availability and characteristics of health care prices and personalized cost estimate tools. Using secret shopper methodology, we called children's hospitals and submitted online estimate requests posing as a self-paying family requesting an out-of-pocket estimate for a tonsillectomy-adenoidectomy.

RESULTS

Eight children's hospital Web sites (18%) listed prices. Twelve (27%) provided personalized cost estimate tool (online form n = 5 and/or phone number n = 9). All 9 hospitals with a phone number for estimates provided the estimated patient liability for a tonsillectomy-adenoidectomy (mean $6008, range $2622-$9840). Of the remaining 36 hospitals without a dedicated price estimate phone number, 21 (58%) provided estimates (mean $7144, range $1200-$15 360). Two of 4 hospitals with online forms provided estimates. Fifteen (39%) state-based Web sites distinguished between prices for pediatric and adult care. One had a personalized cost estimate tool.

CONCLUSIONS

Meaningful prices for pediatric care were not widely available online through children's hospital or state-based price transparency Web sites. A phone line or online form for price estimates were effective strategies for hospitals to provide out-of-pocket price information. Opportunities exist to improve pediatric price transparency.

Categorization of National Pediatric Quality Measures

BACKGROUND AND OBJECTIVE

The number of quality measures has grown dramatically in recent years. This growth has outpaced research characterizing content and impact of these metrics. Our study aimed to identify and classify nationally promoted quality metrics applicable to children, both by type and by content, and to analyze the representation of common pediatric issues among available measures.

METHODS

We identified nationally applicable quality measure collections from organizational databases or clearinghouses, federal Web sites, and key informant interviews and then screened each measure for pediatric applicability. We classified measures as structure, process, or outcome using a Donabedian framework. Additionally, we classified process measures as targeting underuse, overuse, or misuse of health services. We then classified measures by content area and compared disease-specific metrics to frequency of diagnoses observed among children.

RESULTS

A total of 386 identified measures were relevant to pediatric patients; exclusion of duplicates left 257 unique measures. The majority of pediatric measures were process measures (59%), most of which target underuse of health services (77%). Among disease-specific measures, those related to depression and asthma were the most common, reflecting the prevalence and importance of these conditions in pediatrics. Conditions such as respiratory infection and otitis media had fewer associated measures despite their prevalence. Other notable pediatric issues lacking associated measures included care of medically complex children and injuries.

CONCLUSIONS

Pediatric quality measures are predominated by process measures targeting underuse of health care services. The content represented among these measures is broad, although there remain important gaps.

Epidemiology of pediatric hospitalizations at general hospitals and freestanding children's hospitals in the United States

BACKGROUND

Children may be hospitalized at general hospitals or freestanding children's hospitals. Knowledge about how inpatient care differs at these hospitals is important to inform national research and quality efforts.

OBJECTIVE

To describe the volume and characteristics of pediatric hospitalizations at acute care general and freestanding children's hospitals in the United States.

DESIGN, PATIENTS, AND SETTING

Cross-sectional study of hospitalizations in the United States among children <18 years, excluding in-hospital births, using the Healthcare Cost and Utilization Project's 2012 Kids' Inpatient Database.

MEASUREMENT

We examined differences between hospitalizations at general and freestanding children's hospitals, applying weights to generate national estimates. Reasons for hospitalization were categorized using a pediatric grouper, and differences in hospital volumes were assessed for common diagnoses.

RESULTS

A total of 1,407,822 (standard deviation 50,456) hospitalizations occurred at general hospitals, representing 71.7% of pediatric hospitalizations. Hospitalizations at general hospitals accounted for 63.6% of hospital days and 50.0% of pediatric inpatient healthcare costs. Median volumes of pediatric hospitalizations, per hospital, were significantly lower at general hospitals than freestanding children's hospitals for common medical and surgical diagnoses. Although the most common reasons for hospitalization were similar, the most costly conditions differed.

CONCLUSIONS

In 2012, more than 70% of pediatric hospitalizations occurred at general hospitals in the United States. Differences in patterns of care at general hospitals and freestanding children's hospitals may inform clinical programs, research, and quality improvement efforts. Journal of Hospital Medicine 2016;11:743-749. © 2016 Society of Hospital Medicine.

The Creation of a Pediatric Hospital Medicine Dashboard: Performance Assessment for Improvement

BACKGROUND AND OBJECTIVES

Leaders of pediatric hospital medicine (PHM) recommended a clinical dashboard to monitor clinical practice and make improvements. To date, however, no programs report implementing a dashboard including the proposed broad range of metrics across multiple sites. We sought to (1) develop and populate a clinical dashboard to demonstrate productivity, quality, group sustainability, and value added for an academic division of PHM across 4 inpatient sites; (2) share dashboard data with division members and administrations to improve performance and guide program development; and (3) revise the dashboard to optimize its utility.

METHODS

Division members proposed a dashboard based on PHM recommendations. We assessed feasibility of data collection and defined and modified metrics to enable collection of comparable data across sites. We gathered data and shared the results with division members and administrations.

RESULTS

We collected quarterly and annual data from October 2011 to September 2013. We found comparable metrics across all sites for descriptive, productivity, group sustainability, and value-added domains; only 72% of all quality metrics were tracked in a comparable fashion. After sharing the data, we saw increased timeliness of nursery discharges and an increase in hospital committee participation and grant funding.

CONCLUSIONS

PHM dashboards have the potential to guide program development, mobilize faculty to improve care, and demonstrate program value to stakeholders. Dashboard implementation at other institutions and data sharing across sites may help to better define and strengthen the field of PHM by creating benchmarks and help improve the quality of pediatric hospital care.