Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure

OBJECTIVES

To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP).

STUDY DESIGN

Pediatric primary care practices (n = 59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation).

RESULTS

A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension.

CONCLUSIONS

In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03783650.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections

BACKGROUND

Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure.

METHODS

This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage.

RESULTS

A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage.

CONCLUSIONS

CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections

BACKGROUND

Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes.

METHODS

Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors.

RESULTS

Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13).

CONCLUSIONS

Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Mucosal barrier injury-associated bloodstream infections in pediatric oncology patients

BACKGROUND

Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies.

METHODS

Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events.

RESULTS

Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P  <  0.01). Neutropenia was the most common criterion defining MBI-LCBI in both settings, being present in ≥90% of events. The most common organisms isolated in MBI-LCBI events were Escherichia coli (in 28% of events), Klebsiella spp. (23%), and viridans streptococci (12%) in the ambulatory setting and viridans streptococci (in 29% of events), E. coli (14%), and Klebsiella spp. (14%) in the inpatient setting.

CONCLUSION

In this largest study of PHO MBI-LCBI inpatient events and the first such study in the ambulatory setting, the burden of MBI-LCBI across the continuum of care of PHO patients was substantial. These data should raise awareness of MBI-LCBI among healthcare providers for PHO patients, help benchmarking across centers, and help inform prevention and treatment strategies.

Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE

BACKGROUND

Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors.

METHODS

Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts.

RESULTS

Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2-9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors.

CONCLUSIONS

EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.

Comparison of Attention-Deficit/Hyperactivity Disorder Care Between School-Based Health Centers and a Continuity Clinic

BACKGROUND

School-based health centers (SBHC) are in a unique position to provide guideline-driven attention-deficit/hyperactivity disorder (ADHD) care. In this study, we compared adherence to 2 components of ADHD guidelines in SBHC versus a continuity clinic.

METHODS

We compared proportions of ADHD visits that had a structured symptom report available and timely follow-up in SBHC to a continuity clinic using chart review. We used multiple logistic regression to estimate the association between guideline adherence and clinic type.

RESULTS

Participants who had a medication dose change were 3.9 times more likely (relative risk [RR] = 3.9, 95% confidence interval [CI] 3.0-5.1) to have a structured report present and 1.7 times more likely (RR = 1.7, 95% CI 1.2-2.2) to have follow-up within 30 days if they were seen in SBHC versus continuity clinic. Participants who were stable on their medication dose were 18 times more likely (RR = 18.0, 95% CI 11.3-29.0) to have a structured report present and 1.4 times more likely (RR = 1.4, 95% CI 1.3-1.6) to have follow-up within 100 days if they were seen in SBHC versus continuity clinic.

CONCLUSIONS

Care provided in SBHC was associated with improved adherence to guidelines and has the potential to the improve pediatric ADHD outcomes.

Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE

Recognition of childhood hypertension is essential, but pediatricians routinely fail to identify elevated blood pressure (BP). This study investigated if a quality improvement collaborative (QIC) reduces missed elevated BP in primary care.

METHODS

During a cluster-randomized clinical trial, a national cohort worked sequentially to reduce each of three different errors, including missed elevated BP. While working on their first error during an 8-month action period, practices collected control data for a different error. Practices worked to reduce two additional errors in subsequent action periods but continued to provide sustain and maintainenance data on BP. QIC intervention included video learning sessions, transparent data, failures analysis, coaching, and tools to reduce errors. Mixed-effects logistic regression models compared the mean percentage of patients with an elevated BP with appropriate actions taken and documented.

RESULTS

We randomized 43 practices and included 30 in the final analysis. Control and intervention phases included 1,728 and 1,834 patients with an elevated BP, respectively. Comparing control versus intervention phases, the mean percentage of patients who received appropriate actions increased from 58% to 74% [risk difference (RD) 16%; 95% CI;12%, 20%]. Practices continued to improve during the sustain phase as compared to the intervention phase (RD 5%; 95% CI; 2%, 9%) and did not worsen during the maintenance phase (RD 0.9%; 95% CI -5%, 7%).

CONCLUSIONS

Missed pediatric elevated BP can be sustainably reduced via a QIC intervention, demonstrating a possible model for other error reduction efforts.

Pediatric Hospitalizations: Are We Missing an Opportunity to Immunize?

OBJECTIVES

Fewer than half of children receive all recommended immunizations on time. Hospitalizations may be opportunities to address delayed immunizations. Our objectives were to assess (1) prevalence of delayed immunizations among hospitalized patients, (2) missed opportunities to administer delayed immunizations, and (3) time to catch up after discharge.

METHODS

We conducted a retrospective cohort study investigating immunization status of patients 0 to 21 years of age admitted to an academic children's center from 2012 to 2013 at the time of admission, at discharge, and 18 months postdischarge. Immunization catch-up at 18 months postdischarge was defined as having received immunizations due on discharge per Centers for Disease Control and Prevention recommendations. χ² and t test analyses compared characteristics among patients caught up and not caught up at 18 months postdischarge. Analysis of variance and logistic regression analyses compared mean number of immunizations needed and odds of immunization catch-up among age groups. Kaplan-Meier and Cox proportional hazards analyses compared catch-up time by age, race, sex, and insurance.

RESULTS

Among 166 hospitalized patients, 80 were not up to date on immunizations at admission, and only 1 received catch-up immunizations before discharge. Ninety-nine percent (79 of 80) were not up to date on discharge per Centers for Disease Control and Prevention recommendations. Thirty percent (24 of 79), mostly adolescents, were not caught up at 18 months postdischarge. Median postdischarge catch-up time was 3.5 months (range: 0.03-18.0 months). Patients 0 to 35 months of age were more likely to catch up compared with those of other ages (hazard ratio = 2.73; P = .001), with no differences seen when comparing race, sex, or insurance.

CONCLUSIONS

Pediatric hospitalizations provide important opportunities to screen and immunize children.

Hydroxyurea Use for Sickle Cell Disease Among Medicaid-Enrolled Children

BACKGROUND

Recent publications should have resulted in increased hydroxyurea usage in children with sickle cell disease (SCD). We hypothesized that hydroxyurea use in children with SCD increased over time and was associated with decreased acute care visits.

METHODS

This was a secondary analysis of the Truven Health Analytics-IBM Watson Health MarketScan Medicaid database from 2009 to 2015. The multistate, population-based cohort included children 1 to 19 years old with an International Classification of Diseases, Ninth or 10th Revision diagnosis of SCD between 2009 and 2015. Changes in hydroxyurea were measured across study years. The primary outcome was the receipt of hydroxyurea, identified through filled prescription claims. Acute care visits (emergency department visits and hospitalizations) were extracted from billing data.

RESULTS

A mean of 5138 children each year were included. Hydroxyurea use increased from 14.3% in 2009 to 28.2% in 2015 (P < .001). During the study period, the acute-care-visit rate decreased from 1.20 acute care visits per person-year in 2009 to 1.04 acute care visits per person-year in 2015 (P < .001); however, the drop in acute care visits was exclusively in the youngest and oldest age groups and was not seen when only children enrolled continuously from 2009 to 2015 were analyzed.

CONCLUSIONS

There was a significant increase in hydroxyurea use in children with SCD between 2009 and 2015. However, in 2015, only ∼1 in 4 children with SCD received hydroxyurea at least once. Increases in hydroxyurea were not associated with consistently decreased acute care visits in this population-based study of children insured by Medicaid.

Effect of Mental Health Screening and Integrated Mental Health on Adolescent Depression-Coded Visits

Adolescent depression causes morbidity and is underdiagnosed. It is unclear how mental health screening and integrated mental health practitioners change adolescent depression identification. We conducted a retrospective primary care network natural cohort study where 10 out of 19 practices implemented mental health screening, followed by the remaining 9 practices implementing mental health screening with less coaching and support. Afterward, a different subset of 8 practices implemented integrated mental health practitioners. Percentages of depression-coded adolescent visits were compared between practices (1) with and without mental health screening and (2) with and without integrated mental health practitioners, using difference-in-differences analyses. The incidence of depression-coded visits increased more in practices that performed mental health screening (ratio of odds ratios = 1.22; 95% confidence interval =1.00-1.49) and more in practices with integrated mental health practitioners (ratio of odds ratios = 1.58; 95% confidence interval = 1.30-1.93). Adolescent mental health screening and integrated mental health practitioners increase depression-coded visits in primary care.

The design and conduct of Project RedDE: A cluster-randomized trial to reduce diagnostic errors in pediatric primary care

BACKGROUND

Diagnostic errors contribute to the large burden of healthcare-associated harm experienced by children. Primary care settings involve high diagnostic uncertainty and limited time and information, creating ideal conditions for diagnostic errors. We report on the design and conduct of Project RedDE, a stepped-wedge, cluster-randomized controlled trial of a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care.

METHODS

Project RedDE cluster-randomized pediatric primary care practices into one of three groups. Each group participated in a quality improvement collaborative targeting the same three diagnostic errors (missed diagnoses of elevated blood pressure and adolescent depression and delayed diagnoses of abnormal laboratory studies), but in a different sequence. During the quality improvement collaborative, practices worked both independently and collaboratively, leveraging general quality improvement strategies (e.g. process mapping) in addition to error-specific content (e.g. pocket guides for blood pressure norms) delivered during the intervention phase for each error. The quality improvement collaborative intervention included interactive learning sessions and webinars, quality improvement coaching at the team level, and repeated evaluation of failures via root cause analyses. Pragmatic data were collected monthly, submitted to a centralized data aggregator, and returned to the practices in the form of run charts comparing each practice's progress over time to that of the group. The primary analysis used patients as the unit of analysis and compared diagnostic error proportions between the intervention and baseline periods, while secondary analyses evaluated the sustainability of observed reductions in diagnostic errors after the intervention period ended.

RESULTS

A total of 43 practices were recruited and randomized into Project RedDE. Eleven practices withdrew before submitting any data, and one practice merged with another participating practice, leaving 31 practices that began work on Project RedDE. All but one of the diverse, national pediatric primary care practices that participated ultimately submitted complete data. Quality improvement collaborative participation was robust, with an average of 63% of practices present on quality improvement collaborative webinars and 85% of practices present for quality improvement collaborative learning sessions. Complete data included 30 months of outcome data for the first diagnostic error worked on, 24 months of outcome data for the second, and 16 months of data for the third.

LESSONS LEARNED AND LIMITATIONS

Contamination across study groups was a recurring concern; concerted efforts were made to mitigate this risk. Electronic health records played a large role in teams' success.

CONCLUSION

Project RedDE, a virtual quality improvement collaborative aimed at reducing diagnostic errors in pediatric primary care, successfully recruited and retained a diverse, national group of pediatric primary care practices. The stepped-wedge, cluster-randomized controlled trial design allowed for enhanced scientific efficiency.

Diagnostic Errors in Primary Care Pediatrics: Project RedDE

OBJECTIVE

Diagnostic errors (DEs), which encompass failures of accuracy, timeliness, or patient communication, cause appreciable morbidity but are understudied in pediatrics. Pediatricians have expressed interest in reducing high-frequency/subacute DEs, but their epidemiology remains unknown. The objective of this study was to investigate the frequency of two high-frequency/subacute DEs and one missed opportunity for diagnosis (MOD) in primary care pediatrics.

METHODS

As part of a national quality improvement collaborative, 25 primary care pediatric practices were randomized to collect 5 months of retrospective data on one DE or MOD: elevated blood pressure (BP) and abnormal laboratory values (DEs), or adolescent depression evaluation (MOD). Relationships between DE or MOD proportions and patient age, gender, and insurance status were explored with mixed-effects logistic regression models.

RESULTS

DE or MOD rates in pediatric primary care were found to be 54% for patients with elevated BP (n = 389), 11% for patients with abnormal laboratory values (n = 381), and 62% for adolescents with an opportunity to evaluate for depression (n = 400). When examining the number of times a pediatrician may have recognized an abnormal condition but either knowingly or unknowingly did not act according to recommended guidelines, providers did not document recognition of an elevated BP in 51% of patients with elevated BP, and they did not document recognition of an abnormal laboratory value without a delay in 9% of patients with abnormal laboratory values.

CONCLUSIONS

DEs and MODs occur at an appreciable frequency in pediatric primary care. These errors may contribute to care delays and patient harm.

Constipation-Related Emergency Department Use, and Associated Office Visits and Payments Among Commercially Insured Children

OBJECTIVE

Pediatric constipation is common, costly, and often managed in the Emergency Department (ED). The objectives of this study were to determine the frequency of constipation-related ED visits in a large commercially insured population, the frequency of an office visit in the month before and after these visits, demographic characteristics associated with these office visits, and the ED-associated payments.

METHODS

Data were extracted from the Truven MarketScan database for commercially insured children from 2012 to 2013. Data on the presence and timing of clinic visits within 30 days before and after an ED constipation visit and demographic variables were extracted. Logistic regression was used to predict an outcome of presence of a visit with independent variables of age, sex, and region of the country.

RESULTS

In a population of 17 million children aged 0 to 17 years, 448,440 (2.6%) were identified with constipation in at least 1 setting, with 65,163 (14.5%) having an ED visit for constipation. Of all children with a constipation-related ED visit, 45% had no office visit in the 30 days before or after the ED visit. Increasing age was associated with absence of an office visit. The median payment by insurance for an ED constipation visit was $523, the median out-of-pocket payment was $100, for a total of $623 per visit.

CONCLUSION

One in 7 children with constipation in this commercially insured population received ED care for constipation, many without an outpatient visit in the month before or after. Efforts to improve primary care utilization for this condition should be encouraged.

Association of Guideline-Adherent Antibiotic Treatment With Readmission of Children With Sickle Cell Disease Hospitalized With Acute Chest Syndrome

IMPORTANCE

Acute chest syndrome (ACS) is a common, serious complication of sickle cell disease (SCD) and a leading cause of hospitalization and death in both children and adults with SCD. Little is known about the effectiveness of guideline-recommended antibiotic regimens for the care of children hospitalized with ACS.

OBJECTIVES

To use a large, national database to describe patterns of antibiotic use for children with SCD hospitalized for ACS and to determine whether receipt of guideline-adherent antibiotics was associated with lower readmission rates.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort study including 14 480 hospitalizations in 7178 children (age 0-22 years) with a discharge diagnosis of SCD and either ACS or pneumonia. Information was obtained from 41 children's hospitals submitting data to the Pediatric Health Information System from January 1, 2010, to December 31, 2016.

EXPOSURES

National Heart, Lung, and Blood Institute guideline-adherent (macrolide with parenteral cephalosporin) vs non-guideline-adherent antibiotic regimens.

MAIN OUTCOMES AND MEASURES

Acute chest syndrome-related and all-cause 7- and 30-day readmissions.

RESULTS

Of the 14 480 hospitalizations, 6562 (45.3%) were in girls; median (interquartile range) age was 9 (4-14) years. Guideline-adherent antibiotics were provided in 10 654 of 14 480 hospitalizations for ACS (73.6%). Hospitalizations were most likely to include guideline-adherent antibiotics for children aged 5 to 9 years (3230 of 4047 [79.8%]) and declined to the lowest level for children 19 to 22 years (697 of 1088 [64.1%]). Between-hospital variation in antibiotic regimens was wide, with use of guideline-adherent antibiotics ranging from 24% to 90%. Children treated with guideline-adherent antibiotics had lower 30-day ACS-related (odds ratio [OR], 0.71; 95% CI, 0.50-1.00) and all-cause (OR, 0.50; 95% CI, 0.39-0.64) readmission rates vs children who received other regimens (cephalosporin and macrolide vs neither drug class).

CONCLUSIONS AND RELEVANCE

Current approaches to antibiotic treatment in children with ACS vary widely, but guideline-adherent therapy appears to result in fewer readmissions compared with non-guideline-adherent therapy. Efforts to increase the dissemination and implementation of SCD treatment guidelines are warranted as is comparative effectiveness research to strengthen the underlying evidence base.

Electronic Immunization Alerts and Spillover Effects on Other Preventive Care

The impact of electronic health record (EHR) immunization clinical alert systems on the delivery of other preventive services remains unknown. We assessed for spillover effects of an EHR immunization alert on delivery of 6 other preventive services, in children 18 to 30 months of age needing immunizations. We conducted a secondary data analysis, with additional primary data collection, of a randomized, historically controlled trial to improve immunization rates with EHR alerts, in an urban, primary care clinic. No significant differences were found in screening for anemia, lead, development, nutrition, and injury prevention counseling in children prompting EHR immunization alerts (n = 129), compared with controls (n = 135). Significant increases in oral health screening in patients prompting EHR alerts (odds ratio = 4.8, 95% CI = 1.8-13.0) were likely due to practice changes over time. An EHR clinical alert system targeting immunizations did not have a spillover effect on the delivery of other preventive services.

Inhaled Corticosteroid Claims and Outpatient Visits After Hospitalization for Asthma Among Commercially Insured Children

OBJECTIVE

To determine rates of inhaled corticosteroid (ICS) claims and outpatient follow-up after asthma hospitalization among commercially insured children.

METHODS

We conducted a retrospective cohort analysis of children hospitalized for asthma using 2013 national Truven MarketScan data. Covariates included age, sex, region, length of stay, and having an ICS claim within 35 days before hospitalization. Outcome variables were a claim for any ICS-containing medication and outpatient visit within 30 days after discharge. Multivariable analysis used logistic regression.

RESULTS

A total of 5471 children aged 2 to 17 were included; 61% were boys, and mean age was 6.8 years. Forty-one percent had a claim for an ICS and 76% had an outpatient visit within 30 days after hospital discharge. In multivariable analysis, children who had an ICS claim within 35 days before the hospitalization were more likely to have an ICS claim within 30 days after discharge (relative risk [RR] 1.3, 95% confidence interval [CI] 1.2-1.5). The strongest predictor of an ICS claim within 30 days after discharge was attendance at an outpatient appointment (RR 1.4, 95% CI 1.3-1.6). Children aged 2 to 6 were more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.1-1.2). Children with an ICS claim before admission were also more likely to attend an outpatient appointment (RR 1.1, 95% CI 1.004-1.1).

CONCLUSIONS

In this national sample of commercially insured children with asthma, rates of ICS claims after hospitalization are low despite high rates of outpatient visits. Both inpatient and outpatient physicians must play a role in increasing ICS adherence in this high-risk population of children with asthma.

Personalized Reminders Increase Screening for Stroke Risk in Children with Sickle Cell Anemia

OBJECTIVES

Transcranial Doppler ultrasound (TCD) effectively identifies children with sickle cell anemia (SCA) who are at increased risk of stroke. We evaluated a low-cost quality improvement (QI) intervention to increase the proportion of children screened by TCD.

METHODS

We measured the proportion of children with SCA receiving appropriate TCD screening for increased cerebral blood velocity, a marker of stroke risk, for time periods before (April 1, 2009-July 1, 2010) and after (October 1, 2010-January 1, 2012) the implementation of a QI program. We sent eligible families personalized reminder letters, information on screening, and a refrigerator magnet imprinted with the recommended date of TCD screening.

RESULTS

Only 54% (60/112) of children (median age 8 years, range 2.2-16.7 years) had a TCD in the baseline period compared with 79% (87/110; P = 0.0001) after implementation of the QI initiative. The odds of appropriate TCD screening decreased with older age in the baseline period (odds ratio 0.86, 95% confidence interval 0.78-0.94/year; P = 0.001), but not after implementation. Neither predicted travel time by car (median 20 minutes, range 2-164) nor distance traveled (median 9.7 mi, range 0.4-132) was significantly associated with appropriate TCD screening before or after QI implementation. The number needed to treat was four.

CONCLUSIONS

We demonstrated the feasibility and effectiveness of a low-cost QI intervention to increase TCD screening. This approach was more successful than other related intervention models and is easily implemented by smaller sickle cell programs without full-time personnel.

Central Line Associated Blood Stream Infections in Pediatric Hematology/Oncology Patients With Different Types of Central Lines

BACKGROUND

Central line associated bloodstream infections (CLABSIs) are a significant cause of morbidity and mortality in pediatric hematology/oncology (PHO) patients. Understanding the differences in CLABSI rates by central line (CL) type is important to inform clinical decisions.

PROCEDURE

CLABSI, using similar definitions, noted with three commonly used CL types (totally implanted catheter [port], tunneled externalized catheter [TEC], peripherally inserted central catheter [PICC]) and CL-specific line days were prospectively tracked across 15 US PHO centers from May 2012 until April 2015 and CLABSI rates (CLABSI per 1,000 CL-specific line days) were calculated. Host and organism characterstics associated with the CLABSI events were analyzed.

RESULTS

Over the course of 2.8 million line days, 1,113 CLABSI events (397 in inpatients and 716 in ambulatory patients) were noted. The inpatient CLABSI rate was higher than the ambulatory CLABSI rate for each of the CL types: 1.48 versus 0.16 for ports, 3.51 versus 1.38 for TECs, and 3.07 versus 1.16 for PICCs, respectively. TECs and PICCs were associated with higher CLABSI rates than ports, inpatient and ambulatory.

CONCLUSIONS

We found that CLABSI rates were significantly higher for inpatients compared to ambulatory PHO patients for all CL types. Among ambulatory patients, TECs had the highest CLABSI rate and ports the lowest. Among inpatients, TECs and PICCs had higher CLABSI rates than ports but were not statistically different from one another. Cognizant that host and underlying disease attributes may contribute to these differences, these results can still inform CL choice in clinical practice.

Primary care pediatricians' interest in diagnostic error reduction

BACKGROUND

Diagnostic errors causing harm in children are understudied, resulting in a knowledge gap regarding pediatricians' interest in reducing their incidence.

METHODS

Electronic survey of general pediatricians focusing on diagnostic error incidence, errors they were interested in trying to improve, and errors reduced by their electronic health record (EHR).

RESULTS

Of 300 contacted pediatricians, 77 (26%) responded, 58 (19%) served ambulatory patients, and 48 (16%) completed the entire questionnaire. Of these 48, 17 (35%) reported making a diagnostic error at least monthly, and 16 (33%) reported making a diagnostic error resulting in an adverse event at least annually. Pediatricians were "most" interested in "trying to improve" missed diagnosis of hypertension (17%), delayed diagnosis due to missed subspecialty referral (15%), and errors associated with delayed follow-up of abnormal laboratory values (13%). Among the 44 pediatricians with an EHR, 16 (36%) said it reduced the likelihood of missing obesity and 14 (32%) said it reduced the likelihood of missing hypertension. Also, 15 (34%) said it helped avoid delays in follow-up of abnormal laboratory values. A third (36%) reported no help in diagnostic error reduction from their EHR.

CONCLUSIONS

Pediatricians self-report an appreciable number of diagnostic errors and were most interested in preventing high frequency, non-life-threatening errors. There exists a need to leverage EHRs to support error reduction efforts.

State-Mandated Hospital Infection Reporting Is Not Associated With Decreased Pediatric Health Care-Associated Infections

OBJECTIVES

State governments increasingly mandate public reporting of central line-associated blood stream infections (CLABSIs). This study tests if hospitals located in states with state-mandated, facility-identified, pediatric-specific public CLABSI reporting have lower rates of CLABSIs as defined by the Agency for Healthcare Research and Quality's Pediatric Quality Indicator 12 (PDI12).

METHODS

Utilizing the Kids' Inpatient Databases from 2000 to 2009, we compared changes in PDI12 rates across three groups of states: states with public CLABSI reporting begun by 2006, states with public reporting begun by 2009 and never-reporting states. In the baseline period (2000-2003), no states mandated public CLABSI reporting. A multivariable, hospital-level random intercept, logistic regression was performed comparing changes in PDI12 rates in states with public reporting to changes in PDI12 rates in never-reporting states.

RESULTS

4,705,857 discharge records were eligible for PDI12. PDI12 rates significantly decreased in all reporting groups, comparing baseline to the post-public reporting period (2009): Never Reporters 88% decrease (95% CI, 86%-89%), Reporting Begun by 2006 90% decrease (95% CI, 83%-94%), and Reporting Begun by 2009 74% decrease (95% CI, 72%-76%). The Never Reporting Group had comparable decreases in PDI12 rates to the Reporting Begun by 2006 group (P = 0.4) and significantly larger decreases in PDI12 rates compared to the Reporting Begun by 2009 group (P < 0.001), despite having no states with public reporting.

CONCLUSIONS

Public CLABSI reporting alone appears to be insufficient to affect administrative data-based measures of pediatric CLABSI rates or children may be inadequately targeted in current public reporting efforts.

Burden of bloodstream infections among ambulatory pediatric hematology/oncology patients with a central line

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Background: Pediatric hematology/oncology (PHO) patients are at high risk of bloodstream infections (BSI). The burden of BSI in PHO patients in the ambulatory setting has not been well documented. Methods: The Children’s Hospital Association leads the Childhood Cancer and Blood Disorders Network, a multicenter United States quality improvement collaborative, working to reduce the incidence of inpatient and ambulatory Central Line-Associated BSI (CLABSI) among PHO patients. Positive blood culture events (+BCE) were adjudicated as CLABSI, single positive blood cultures (SPBC) with potential commensals, or secondary BSI (attributed to source other than the central line) following standardized National Healthcare Safety Network definitions. Our study investigated the prevalence of +BCE among all centers with 90% complete monthly reporting of both +BCE and central line days (CLD) for at least one year (n=25) between January 2012 and September 2014. Ambulatory and inpatient BSI rates and 95% confidence intervals (CI) were calculated as the number of +BCE per 1,000 CLD per month. Results: A total of 1,747 +BCE and 4,883,413 CLD were reported among our target ambulatory population, whereas 1,095 +BCE and 353,259 CLD were reported among our corresponding inpatient population [Table]. While the CLABSI and SPBC rates were significantly lower in the ambulatory setting compared to inpatient (p<0.001), the total number of ambulatory CLABSI and SPBC events was 2.0 and 1.6 times higher than inpatient events, respectively. Conclusions: Our findings from a large multicenter collaborative demonstrate the burden of BSI among ambulatory PHO patients and identify benchmarks for future quality improvement work.Further investigation is necessary to develop effective infection reduction strategies for ambulatory PHO patients with central lines. [Table: see text]

Association between Hospital Volume and Within-Hospital Intensive Care Unit Transfer for Sickle Cell Disease in Children's Hospitals

OBJECTIVE

To assess the relationship between hospital volume and intensive care unit (ICU) transfer among hospitalized children with sickle cell disease (SCD).

STUDY DESIGN

We conducted a retrospective cohort study of 83,477 SCD-related hospitalizations at children's hospitals (2009-2012) using the Pediatric Health Information System database. Hospital-level all-cause and SCD-specific volumes were dichotomized (low vs high). Outcomes were within-hospital ICU transfer (primary) and length of stay (LOS) total (secondary). Multivariable logistic/linear regressions assessed the association of hospital volumes with ICU transfer and LOS.

RESULTS

Of 83,477 eligible hospitalizations, 1741 (2.1%) involving 1432 unique children were complicated by ICU transfer. High SCD-specific volume (OR 0.77, 95% CI 0.64-0.91) was associated with lower odds of ICU transfer while high all-cause hospital volume was not (OR 0.87, 95% CI 0.73-1.04). A statistically significant interaction was found between all-cause and SCD-specific volumes. When results were stratified according to all-cause volume, high SCD-specific volume was associated with lower odds of ICU transfer at low all-cause volume (OR 0.46, 95% CI 0.38-0.55). High hospital volumes, both all-cause (OR 0.94, 95% CI 0.92-0.97) and SCD-specific (OR 0.86, 95% CI 0.84-0.88), were associated with shorter LOS.

CONCLUSIONS

Children's hospitals vary substantially in their transfer of children with SCD to the ICU according to hospital volumes. Understanding the practices used by different institutions may help explain the variability in ICU transfer among hospitals caring for children with SCD.

Bringing central line-associated bloodstream infection prevention home: catheter maintenance practices and beliefs of pediatric oncology patients and families

BACKGROUND

A study was conducted to investigate (1) the extent to which best-practice central line maintenance practices were employed in the homes of pediatric oncology patients and by whom, (2) caregiver beliefs about central line care and central line-associated blood stream infection (CLABSI) risk, (3) barriers to optimal central line care by families, and (4) educational experiences and preferences regarding central line care.

METHODS

Researchers administered a survey to patients and families in a tertiary care pediatric oncology clinic that engaged in rigorous ambulatory and inpatient CLABSI prevention efforts.

RESULTS

Of 110 invited patients and caregivers, 105 participated (95% response rate) in the survey (March-May 2012). Of the 50 respondents reporting that they or another caregiver change central line dressings, 48% changed a dressing whenever it was soiled as per protocol (many who did not change dressings per protocol also never personally changed dressings); 67% reported the oncology clinic primarily cares for their child's central line, while 29% reported that an adult caregiver or the patient primarily cares for the central line. Eight patients performed their own line care "always" or "most of the time." Some 13% of respondents believed that it was "slightly likely" or "not at all likely" that their child will get an infection if caregivers do not perform line care practices perfectly every time. Dressing change practices were the most difficult to comply with at home. Some 18% of respondents wished they learned more about line care, and 12% received contradictory training. Respondents cited a variety of preferences regarding line care teaching, although the majority looked to clinic nurses for modeling line care.

CONCLUSIONS

Interventions aimed at reducing ambulatory CLABSIs should target appropriate educational experiences for adult caregivers and patients and identify ways to improve compliance with best-practice care.

Transcranial Doppler screening of Medicaid-insured children with sickle cell disease

Transcranial Doppler screening reduces the risk of stroke in children with sickle cell disease. We tested the effect of informational letters sent to parents and doctors of Medicaid-insured children on improving screening efficiency. The letters did not improve the low baseline screening rates, suggesting the need for more aggressive outreach. Hematologist visits were correlated with increased screening rates.

Medication adherence among pediatric patients with sickle cell disease: a systematic review

OBJECTIVES

Describe rates of adherence for sickle cell disease (SCD) medications, identify patient and medication characteristics associated with nonadherence, and determine the effect of nonadherence and moderate adherence (defined as taking 60%-80% of doses) on clinical outcomes.

METHODS

In February 2012 we systematically searched 6 databases for peer-reviewed articles published after 1940. We identified articles evaluating medication adherence among patients <25 years old with SCD. Two authors reviewed each article to determine whether it should be included. Two authors extracted data, including medication studied, adherence measures used, rates of adherence, and barriers to adherence.

RESULTS

Of 24 articles in the final review, 23 focused on 1 medication type: antibiotic prophylaxis (13 articles), iron chelation (5 articles), or hydroxyurea (5 articles). Adherence rates ranged from 16% to 89%; most reported moderate adherence. Medication factors contributed to adherence. For example, prophylactic antibiotic adherence was better with intramuscular than oral administration. Barriers included fear of side effects, incorrect dosing, and forgetting. Nonadherence was associated with more vaso-occlusive crises and hospitalizations. The limited data available on moderate adherence to iron chelation and hydroxyurea indicates some clinical benefit.

CONCLUSIONS

Moderate adherence is typical among pediatric patients with SCD. Multicomponent interventions are needed to optimally deliver life-changing medications to these children and should include routine monitoring of adherence, support to prevent mistakes, and education to improve understanding of medication risks and benefits.

Preventing CLABSIs among pediatric hematology/oncology inpatients: national collaborative results

OBJECTIVES

Central lines (CLs) are essential for the delivery of modern cancer care to children. Nonetheless, CLs are subject to potentially life-threatening complications, including central line-associated bloodstream infections (CLABSIs). The objective of this study was to assess the feasibility of a multicenter effort to standardize CL care and CLABSI tracking, and to quantify the impact of standardizing these processes on CLABSI rates among pediatric hematology/oncology inpatients.

METHODS

We conducted a multicenter quality improvement collaborative starting in November 2009. Multidisciplinary teams at participating sites implemented a standardized bundle of CL care practices and adopted a common approach to CLABSI surveillance.

RESULTS

Thirty-two units participated in the collaborative and reported a mean, precollaborative CLABSI rate of 2.85 CLABSIs per 1000 CL-days. Self-reported adoption of the CL care bundle was brisk, with average compliance approaching 80% by the end of the first year of the collaborative and exceeding 80% thereafter. As of August 2012, the mean CLABSI rate during the collaborative was 2.04 CLABSIs per 1000 CL-days, a reduction of 28% (relative risk: 0.71 [95% confidence interval: 0.55-0.92]). Changes in self-reported CL care bundle compliance were not statistically associated with changes in CLABSI rates, although there was little variability in bundle compliance rates after the first year of the collaborative.

CONCLUSIONS

A multicenter quality improvement collaborative found significant reductions in observed CLABSI rates in pediatric hematology/oncology inpatients. Additional interventions will likely be required to bring and sustain CLABSI rates closer to zero for this high-risk population.

Education in Quality Improvement for Pediatric Practice: an online program to teach clinicians QI

BACKGROUND

Education in Quality Improvement for Pediatric Practice (EQIPP) is an online program designed to improve evidence-based care delivery by teaching front-line clinicians quality improvement (QI) skills. Our objective was to evaluate EQIPP data to characterize 1) participant enrollment, use patterns, and demographics; 2) changes in performance in clinical QI measures from baseline to follow-up measurement; and 3) participant experience.

METHODS

We conducted an observational study of EQIPP participants utilizing 1 of 3 modules (asthma, immunizations, gastroesophageal reflux disease) from 2009 to 2013. Enrollment and use, demographic, and quality measure data were extracted directly from the EQIPP system; participant experience was assessed via an optional online survey.

RESULTS

Study participants (n = 3501) were diverse in their gender, age, and race; most were board certified. Significant quality gaps were observed across many of the quality measures at baseline; sizable improvements were observed across most quality measures at follow-up. Participants were generally satisfied with their experience. The most influential module elements were collecting and analyzing data, creating and implementing aim statements and improvement plans, and completing "QI Basics."

CONCLUSIONS

Online educational programs, such as EQIPP, hold promise for front-line clinicians to learn QI. The sustainability of the observed improvements in care processes and their linkage to improvements in health outcomes are unknown and are an essential topic for future study.

Interventions to reduce pediatric medication errors: a systematic review

BACKGROUND AND OBJECTIVE

Medication errors cause appreciable morbidity and mortality in children. The objective was to determine the effectiveness of interventions to reduce pediatric medication errors, identify gaps in the literature, and perform meta-analyses on comparable studies.

METHODS

Relevant studies were identified from searches of PubMed, Embase, Scopus, Web of Science, the Cochrane Library, and the Cumulative Index to Nursing Allied Health Literature and previous systematic reviews. Inclusion criteria were peer-reviewed original data in any language testing an intervention to reduce medication errors in children. Abstract and full-text article review were conducted by 2 independent authors with sequential data extraction.

RESULTS

A total of 274 full-text articles were reviewed and 63 were included. Only 1% of studies were conducted at community hospitals, 11% were conducted in ambulatory populations, 10% reported preventable adverse drug events, 10% examined administering errors, 3% examined dispensing errors, and none reported cost-effectiveness data, suggesting persistent research gaps. Variation existed in the methods, definitions, outcomes, and rate denominators for all studies; and many showed an appreciable risk of bias. Although 26 studies (41%) involved computerized provider order entry, a meta-analysis was not performed because of methodologic heterogeneity. Studies of computerized provider order entry with clinical decision support compared with studies without clinical decision support reported a 36% to 87% reduction in prescribing errors; studies of preprinted order sheets revealed a 27% to 82% reduction in prescribing errors.

CONCLUSIONS

Pediatric medication errors can be reduced, although our understanding of optimal interventions remains hampered. Research should focus on understudied areas, use standardized definitions and outcomes, and evaluate cost-effectiveness.

Respiratory syncytial virus and seasonal influenza cause similar illnesses in children with sickle cell disease

BACKGROUND

Respiratory syncytial virus (RSV) is a cause of acute chest syndrome (ACS) in sickle cell disease (SCD), but its clinical course and acute complications have not been well characterized. We compared RSV to seasonal influenza infections in children with SCD.

PROCEDURE

We defined cases as laboratory-confirmed RSV or seasonal influenza infection in inpatients and outpatients <18 years of age with SCD from 1 September 1993 to 30 June 2011. We used Fisher's exact test to compare proportions, Student's t-test or Wilcoxon rank-sum test to compare continuous variables, and logistic regression to evaluate associations.

RESULTS

We identified 64 children with RSV and 91 with seasonal influenza. Clinical symptoms, including fever, cough, and rhinorrhea were similar for RSV and influenza, as were complications, including ACS and treatments for SCD. In a multivariable logistic regression model, older age (OR 1.2 per year, 95% CI [1.02-1.5], P = 0.04), increased white blood cell count at presentation (OR 1.1 per 1,000/μl increase, 95% CI [1.03-1.3], P = 0.008), and a history of asthma (OR 7, 95% [CI 1.3-37], P = 0.03) were independently associated with increased risk of ACS in children with RSV. The hospitalization rate for children with SCD and RSV (40 per 1,000 <5 years and 63 per 1,000 <2 years) greatly exceeds the general population (3 in 1,000 <5 years).

CONCLUSIONS

We conclude that RSV infection is often associated with ACS and similar in severity to influenza infection in febrile children with SCD.

Ambulatory pediatric oncology CLABSIs: epidemiology and risk factors

BACKGROUND

To compare the burden of central line-associated bloodstream infections (CLABSIs) in ambulatory versus inpatient pediatric oncology patients, and identify the epidemiology of and risk factors associated with ambulatory CLABSIs.

PROCEDURE

We prospectively identified infections and retrospectively identified central line days and characteristics associated with CLABSIs from January 2009 to October 2010. A nested case-control design was used to identify characteristics associated with ambulatory CLABSIs.

RESULTS

We identified 319 patients with central lines. There were 55 ambulatory CLABSIs during 84,705 ambulatory central line days (0.65 CLABSIs per 1,000 central line days (95% CI 0.49, 0.85)), and 19 inpatient CLABSIs during 8,682 inpatient central line days (2.2 CLABSIs per 1,000 central lines days (95% CI 1.3, 3.4)). In patients with ambulatory CLABSIs, 13% were admitted to an intensive care unit and 44% had their central lines removed due to the CLABSI. A secondary analysis with a sub-cohort, suggested children with tunneled, externalized catheters had a greater risk of ambulatory CLABSI than those with totally implantable devices (IRR 20.6, P < 0.001). Other characteristics independently associated with ambulatory CLABSIs included bone marrow transplantation within 100 days (OR 16, 95% CI 1.1, 264), previous bacteremia in any central line (OR 10, 95% CI 2.5, 43) and less than 1 month from central line insertion (OR 4.2, 95% CI 1.0, 17).

CONCLUSIONS

In pediatric oncology patients, three times more CLABSIs occur in the ambulatory than inpatient setting. Ambulatory CLABSIs carry appreciable morbidity and have identifiable, associated factors that should be addressed in future ambulatory CLABSI prevention efforts.

Central line maintenance bundles and CLABSIs in ambulatory oncology patients

OBJECTIVE

Pediatric oncology patients are frequently managed with central lines as outpatients, and these lines confer significant morbidity in this immune-compromised population. We aimed to investigate whether a multidisciplinary, central line maintenance care bundle reduces central line-associated bloodstream infections (CLABSIs) and bacteremias in ambulatory pediatric oncology patients.

METHODS

We conducted an interrupted time-series study of a maintenance bundle concerning all areas of central line care. Each of 3 target groups (clinic staff, homecare agency nurses, and patient families) (1) received training on the bundle and its importance, (2) had their practice audited, and (3) were shown CLABSI rates through graphs, in-service training, and bulletin boards. CLABSI and bacteremia person-time incidence rates were collected for 23 months before and 24 months after beginning the intervention and were compared by using a Poisson regression model.

RESULTS

The mean CLABSI rate decreased by 48% from 0.63 CLABSIs per 1000 central line days at baseline to 0.32 CLABSIs per 1000 central line days during the intervention period (P = .005). The mean bacteremia rate decreased by 54% from 1.27 bacteremias per 1000 central line days at baseline to 0.59 bacteremias per 1000 central line days during the intervention period (P < .001).

CONCLUSIONS

Implementation of a multidisciplinary, central line maintenance care bundle significantly reduced CLABSI and bacteremia person-time incidence rates in ambulatory pediatric oncology patients with central lines. Further research is needed to determine if maintenance care bundles reduce ambulatory CLABSIs and bacteremia in other adult and pediatric populations.

Bringing central line-associated bloodstream infection prevention home: CLABSI definitions and prevention policies in home health care agencies

BACKGROUND

A study was conducted to investigate health care agency central line-associated bloodstream infection (CLABSI) definitions and prevention policies and pare them to the Joint Commission National Patient Safety Goal (NPSG.07.04.01), the Centers for Disease Control and Prevention (CDC) CLABSI prevention recommendations, and a best-practice central line care bundle for inpatients.

METHODS

A telephone-based survey was conducted in 2011 of a convenience sample of home health care agencies associated with children's hematology/oncology centers.

RESULTS

Of the 97 eligible home health care agencies, 57 (59%) completed the survey. No agency reported using all five aspects of the National Healthcare and Safety Network/Association for Professionals in Infection Control and Epidemiology CLABSI definition and adjudication process, and of the 50 agencies that reported tracking CLABSI rates, 20 (40%) reported using none. Only 10 agencies (18%) had policies consistent with all elements of the inpatient-focused NPSG.07.04.01, 10 agencies (18%) were consistent with all elements of the home care targeted CDC CLABSI prevention recommendations, and no agencies were consistent with all elements of the central line care bundle. Only 14 agencies (25%) knew their overall CLABSI rate: mean 0.40 CLABSIs per 1,000 central line days (95% confidence interval [CI], 0.18 to 0.61). Six agencies (11%) knew their agency's pediatric CLABSI rate: mean 0.54 CLABSIs per 1,000 central line days (95% CI, 0.06 to 1.01).

CONCLUSIONS

The policies of a national sample of home health care agencies varied significantly from national inpatient and home health care agency targeted standards for CLABSI definitions and prevention. Future research should assess strategies for standardizing home health care practices consistent with evidence-based recommendations.

Surveillance of hospital-acquired central line-associated bloodstream infections in pediatric hematology-oncology patients: lessons learned, challenges ahead

Across 36 US pediatric oncology centers, 576 central line-associated bloodstream infections (CLABSIs) were reported over a 21-month period. Most infections occurred in those with leukemia and/or profound neutropenia. The contribution of viridans streptococci infections was striking. Study findings depict the contemporary epidemiology of CLABSIs in hospitalized pediatric cancer patients.

Improving immunization delivery using an electronic health record: the ImmProve project

OBJECTIVE

Though an essential pediatric preventive service, immunizations are challenging to deliver reliably. Our objective was to measure the impact on pediatric immunization rates of providing clinicians with electronic health record-derived immunization prompting.

METHODS

Operating in a large, urban, hospital-based pediatric primary care clinic, we evaluated 2 interventions to improve immunization delivery to children ages 2, 6, and 13 years: point-of-care, patient-specific electronic clinical decision support (CDS) when children overdue for immunizations presented for care, and provider-specific bulletins listing children overdue for immunizations.

RESULTS

Overall, the proportion of children up to date for a composite of recommended immunizations at ages 2, 6, and 13 years was not different in the intervention (CDS active) and historical control (CDS not active) periods; historical immunization rates were high. The proportion of children receiving 2 doses of hepatitis A immunization before their second birthday was significantly improved during the intervention period. Human papillomavirus (HPV) immunization delivery was low during both control and intervention periods and was unchanged for 13-year-olds. For 14-year-olds, however, 4 of the 5 highest quarterly rates of complete HPV immunization occurred in the final year of the intervention. Provider-specific bulletins listing children overdue for immunizations increased the likelihood of identified children receiving catch-up hepatitis A immunizations (hazard ratio 1.32; 95% confidence interval 1.12-1.56); results for HPV and the composite of recommended immunizations were of a similar magnitude but not statistically significant.

CONCLUSIONS

In our patient population, with high baseline uptake of recommended immunizations, electronic health record-derived immunization prompting had a limited effect on immunization delivery. Benefit was more clearly demonstrated for newer immunizations with lower baseline uptake.

Ambulatory care connections of Medicaid-insured children with sickle cell disease

BACKGROUND

Sickle cell disease (SCD) requires coordinated ambulatory care from generalists and hematologists. We examined when children with SCD establish ambulatory care connections, whether these connections are maintained, and how these connections are used before and after hospitalizations.

PROCEDURE

We conducted a retrospective cohort study of Medicaid-insured Maryland children with SCD from 2002 to 2008. For children enrolled from birth, time to first, second, and third generalist and first hematologist visits was plotted. For all children, we analyzed ambulatory visits by age group, by emergency department (ED) and hospital use, and before and after hospitalizations.

RESULTS

The overall study cohort comprised 851 children; 178 provided data from birth. Ambulatory care connections to generalists were made rapidly; connections to hematologists occurred more slowly, if at all (38% of children had not seen a hematologist by age 2 years). Visits with generalists decreased as patients aged, as did visits with hematologists (54% of children in the 12-17 year age group had no hematology visits in 2 years). Children with higher numbers of ED visits or hospitalizations also had higher numbers of ambulatory visits (generalist and hematologist). Most children had visits with neither generalists nor hematologists in the 30 days before and after hospitalizations.

CONCLUSIONS

Medicaid-insured children with SCD rapidly connect with generalists after birth; connections to hematologists occur more slowly. The observation that connections to generalists and hematologists diminish with time and are infrequently used around hospitalizations suggests that the ambulatory care of many Medicaid-insured children with SCD may be inadequate.

Implementation of a central line maintenance care bundle in hospitalized pediatric oncology patients

OBJECTIVE

To investigate whether a multidisciplinary, best-practice central line maintenance care bundle reduces central line-associated blood stream infection (CLABSI) rates in hospitalized pediatric oncology patients and to further delineate the epidemiology of CLABSIs in this population.

METHODS

We performed a prospective, interrupted time series study of a best-practice bundle addressing all areas of central line care: reduction of entries, aseptic entries, and aseptic procedures when changing components. Based on a continuous quality improvement model, targeted interventions were instituted to improve compliance with each of the bundle elements. CLABSI rates and epidemiological data were collected for 10 months before and 24 months after implementation of the bundle and compared in a Poisson regression model.

RESULTS

CLABSI rates decreased from 2.25 CLABSIs per 1000 central line days at baseline to 1.79 CLABSIs per 1000 central line days during the intervention period (incidence rate ratio [IRR]: 0.80, P = .58). Secondary analyses indicated CLABSI rates were reduced to 0.81 CLABSIs per 1000 central line days in the second 12 months of the intervention (IRR: 0.36, P = .091). Fifty-nine percent of infections resulted from Gram-positive pathogens, 37% of patients with a CLABSI required central line removal, and patients with Hickman catheters were more likely to have a CLABSI than patients with Infusaports (IRR: 4.62, P = .02).

CONCLUSIONS

A best-practice central line maintenance care bundle can be implemented in hospitalized pediatric oncology patients, although long ramp-up times may be necessary to reap maximal benefits. Further research is needed to determine if this CLABSI rate reduction can be sustained and spread.

Generational status, health insurance, and public benefit participation among low-income Latino children

The objectives of this study were to (1) measure health insurance coverage and continuity across generational subgroups of Latino children, and (2) determine if participation in public benefit programs is associated with increased health insurance coverage and continuity. We analyzed data on 25,388 children income-eligible for public insurance from the 2003 to 2004 National Survey of Children's Health and stratified Latinos by generational status. First- and second-generation Latino children were more likely to be uninsured (58 and 19%, respectively) than third-generation children (9.5%). Second-generation Latino children were similarly likely to be currently insured by public insurance as third-generation children (61 and 62%, respectively), but less likely to have private insurance (19 and 29%, respectively). Second-generation Latino children were slightly more likely than third-generation children to have discontinuous insurance during the year (19 and 15%, respectively). Compared with children in families where English was the primary home language, children in families where English was not the primary home language had higher odds of being uninsured versus having continuous insurance coverage (OR: 2.19; 95% CI [1.33-3.62]). Among second-generation Latino children, participation in the Food Stamp (OR 0.26; 95% CI [0.14-0.48]) or Women, Infants, and Children (OR 0.40; 95% CI [0.25-0.66]) programs was associated with reduced odds of being uninsured. Insurance disparities are concentrated among first- and second-generation Latino children. For second-generation Latino children, connection to other public benefit programs may promote enrollment in public insurance.

Electronic health record-based monitoring of primary care patients at risk of medication-related toxicity

BACKGROUND

Timely laboratory monitoring may reduce the potential harm associated with chronic medication use. A study was conducted to determine the proportion of patients receiving National Committee for Quality Assurance (NCQA)-recommended laboratory medication monitoring in a primary care setting and to assess the effect of electronic health record (EHR)-derived, paper-based, provider-specific feedback bulletins on subsequent patient receipt of medication monitoring.

METHODS

In a single-arm, pre-post intervention in two federally qualified community health centers in Baltimore, patients targeted were adults prescribed at least 6 months (in the preceding year) for at least one index medication (digoxin, statins, diuretics, angiotensin-converting enzyme inhibitors/ angiotensin II-receptor blockers) in a 12-month period (August 2008-July 2009).

RESULTS

Among the 2,013 patients for whom medication monitoring was recommended, 42% were overdue for monitoring at some point during the study. As the number of index medications the patient was prescribed increased, the likelihood of ever being overdue for monitoring decreased. Being listed on the provider-specific monitoring bulletin doubled the odds of a patient receiving recommended laboratory monitoring before the next measurement period (1-2 months). Limiting the intervention to the most overdue patients, however, mitigated its overall impact.

CONCLUSIONS

Recommended laboratory monitoring of chronic medications appears to be inconsistent in primary care, resulting in potential harm for individuals at risk for medication-related toxicity. EHRs may be an important component of systems designed to improve medication monitoring, but multimodal interventions will likely be needed to achieve high reliability.

Accuracy and usefulness of the HEDIS childhood immunization measures

OBJECTIVE

With the use of Centers for Disease Control and Prevention (CDC) immunization recommendations as the gold standard, our objectives were to measure the accuracy ("is this child up-to-date on immunizations?") and usefulness ("is this child due for catch-up immunizations?") of the Healthcare Effectiveness Data and Information Set (HEDIS) childhood immunization measures.

METHODS

For children aged 24 to 35 months from the 2009 National Immunization Survey, we assessed the accuracy and usefulness of the HEDIS childhood immunization measures for 6 individual immunizations and a composite.

RESULTS

A total of 12 096 children met all inclusion criteria and composed the study sample. The HEDIS measures had >90% accuracy when compared with the CDC gold standard for each of the 6 immunizations (range, 94.3%-99.7%) and the composite (93.8%). The HEDIS measure was least accurate for hepatitis B and pneumococcal conjugate immunizations. The proportion of children for which the HEDIS measure yielded a nonuseful result (ie, an incorrect answer to the question, "is this child due for catch-up immunization?") ranged from 0.33% (varicella) to 5.96% (pneumococcal conjugate). The most important predictor of HEDIS measure accuracy and usefulness was the CDC-recommended number of immunizations due at age 2 years; children with zero or all immunizations due were the most likely to be correctly classified.

CONCLUSIONS

HEDIS childhood immunization measures are, on the whole, accurate and useful. Certain immunizations (eg, hepatitis B, pneumococcal conjugate) and children (eg, those with a single overdue immunization), however, are more prone to HEDIS misclassification.

A policy impact analysis of the mandatory NCAA sickle cell trait screening program

OBJECTIVE

To estimate the impact of the mandatory National Collegiate Athletic Association (NCAA) sickle cell trait (SCT) screening policy on the identification of sickle cell carriers and prevention of sudden death.

DATA SOURCE

We used NCAA reports, population-based SCT prevalence estimates, and published risks for exercise-related sudden death attributable to SCT.

STUDY DESIGN

We estimated the number of sickle cell carriers identified and the number of potentially preventable sudden deaths with mandatory SCT screening of NCAA Division I athletes. We calculated the number of student-athletes with SCT using a conditional probability based upon SCT prevalence data and self-identified race/ethnicity status. We estimated sudden deaths over 10 years based on published attributable risk of exercise-related sudden death due to SCT.

PRINCIPAL FINDINGS

We estimate that over 2,000 NCAA Division I student-athletes with SCT will be identified under this screening policy and that, without intervention, about seven NCAA Division I student-athletes would die suddenly as a complication of SCT over a 10-year period.

CONCLUSION

Universal sickle cell screening of NCAA Division I student-athletes will identify a substantial number of sickle cell carriers. A successful intervention could prevent about seven deaths over a decade.

Urgency of emergency department visits by children with sickle cell disease: a comparison of 3 chronic conditions

OBJECTIVE

Children with sickle cell disease (SCD) often receive care in the emergency department (ED), but the urgency of these frequent visits is not well understood. This study examined ED use by children with SCD by comparing the urgency of ED visits among children with SCD, asthma, and diabetes mellitus.

METHODS

We conducted a retrospective cohort study of Maryland ED visits for SCD, diabetes, or asthma from 2000 to 2004. ED visits resulting in hospital admission were deemed urgent. The urgency of ED visits not resulting in admission was determined using 2 methodologies: evaluation and management (E/M) coding and resource utilization. Multivariable logistic regression models were used to compare the likelihood of admission or urgent, treat-and-release ED visits across the 3 chronic conditions.

RESULTS

Nearly half (45%) of ED visits with a primary diagnosis of SCD resulted in admission, which was substantially higher than the 12% seen for asthma (adjusted odds ratio [AOR] 6.9, 95% confidence interval [CI], 6.4-7.4) and comparable to that seen for diabetes (41%). ED visits associated with primary diagnoses of SCD (AOR 5.9, 95% CI, 5.3-6.5) and diabetes (AOR 6.6, 95% CI, 6.0-7.3) were more likely than those associated with asthma to result in either admission or a discharge of higher urgency, as measured by E/M coding. These relationships persisted among repeat ED visitors, for visits with any diagnosis (ie, primary or nonprimary) of SCD, diabetes, and asthma, and when evaluated using the resource utilization method.

CONCLUSIONS

Similar to visits by children with diabetes, ED visits by children with SCD are substantially more likely than those by children with asthma to be of high urgency.

Burden of influenza-related hospitalizations among children with sickle cell disease

OBJECTIVE

Children with sickle cell disease (SCD) are considered to be at high risk for complications from influenza infection despite minimal published data that characterize the burden of influenza in this population. Our objectives were to (1) estimate the rate of influenza-related hospitalizations (IRHs) among children with SCD, (2) compare this rate with rates of children with cystic fibrosis (CF) and children with neither SCD nor CF, and (3) explore mechanisms that underlie these potentially preventable hospitalizations.

METHODS

We analyzed hospitalizations from 4 states (California, Florida, Maryland, and New York) across 2 influenza seasons (2003-2004 and 2004-2005) from the Healthcare Cost and Utilization Project State Inpatient Databases. We included hospitalizations with a discharge diagnosis code for influenza in a child <18 years of age. We used census data and disease prevalence estimates to calculate denominators and compare rates of IRH among children with SCD, CF, and neither disease.

RESULTS

There were 7896 pediatric IRHs during the 2 influenza seasons. Of these, 159 (2.0%) included a co-occurring diagnosis of SCD. Annual rates of IRHs were 112 and 2.0 per 10 000 children with and without SCD, respectively, across both seasons. Children with SCD were hospitalized with influenza at 56 times (95% confidence interval: 48-65) the rate of children without SCD. Children with SCD had approximately double the risk of IRH compared with children with CF (risk ratio: 2.1 [95% confidence interval: 1.5-2.9]). IRHs among children with SCD were not longer, more costly, or more severe than IRHs among children without SCD; they were also rarely nosocomial and co-occurred with a diagnosis of asthma in 14% of cases.

CONCLUSIONS

IRHs are substantially more common among children with SCD than among those without the disease, which supports the potential importance of vigorous influenza vaccination efforts that target children with SCD.