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Remer LM, Line K, Paolella A, Rozniak JM, Alessandrini EA. Use of Daily Web-Based, Real-Time Feedback to Improve Patient and Family Experience. J Patient Exp 2024; 11:23743735241226994. [PMID: 38601264 PMCID: PMC11005486 DOI: 10.1177/23743735241226994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2024] Open
Abstract
Real-time feedback is a growing trend in patient- and family experience (PFE) work as it allows for immediate service recovery, though it typically requires a significant investment of time and financial resources. We describe a partnership with our "edutainment" system to administer an automated daily experience question (the "Daily Pulse Measure [DPM]") that allowed targeted just-in-time responses to low scores with minimal administrative cost. Through a series of Plan-Do-Study-Act cycles guided by family feedback, the question was created and modified, and the use of the question spread to all hospital units. The response rate was 23%, similar to our Hospital Consumer Assessment of Healthcare Providers and Systems survey response rate of 24% during the study period. Though the DPM did not have a consistent impact on the results of the 2 PFE survey questions we evaluated, units with improved PFE scores after the DPM roll-out tended to have more robust service recovery than those with low scores.
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Affiliation(s)
- Lisa M Remer
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Kristin Line
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Alyssa Paolella
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Justin M Rozniak
- Department of Information Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Evaline A Alessandrini
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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Fant C, Marin JR, Ramgopal S, Simon NJE, Richards R, Olsen CS, Alessandrini EA, Alpern ER. Updated Diagnosis Grouping System for Pediatric Emergency Department Visits. Pediatr Emerg Care 2023; 39:299-303. [PMID: 35881008 DOI: 10.1097/pec.0000000000002692] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study aims to update the Diagnosis Grouping System (DGS) for International Classification of Disease, Tenth Revision ( ICD-10 ) codes for ongoing use. The DGS was developed in 2010 using ICD-9 codes with 21 major groups and 27 subgroups to facilitate research on pediatric patients presenting to emergency departments and required updated classification for more recent ICD codes. METHODS All emergency department discharges available in the Pediatric Emergency Care Applied Research Network (PECARN) database for 2016 were included to identify ICD-10 codes. These codes were then mapped onto the DGS codes originally derived from ICD-9 . We used ICD-10 codes from the PECARN database from 2017 to 2019 to confirm validity. RESULTS The DGS was updated with ICD-10 codes based on 2016 PECARN data, and this updated DGS was successfully applied to 6,853,479 (97.3%) of all codes from 2017 to 2019. DISCUSSION Using ICD-10 codes from the PECARN Registry, the DGS was updated to reflect ICD-10 codes to facilitate ongoing research.
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Affiliation(s)
- Colleen Fant
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Jennifer R Marin
- Department of Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Sriram Ramgopal
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Norma-Jean E Simon
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | | | | | | | - Elizabeth R Alpern
- From the Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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3
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Johnson TJ, Goyal MK, Lorch SA, Chamberlain JM, Bajaj L, Alessandrini EA, Simmons T, Casper TC, Olsen CS, Grundmeier RW, Alpern ER. Racial/Ethnic Differences in Pediatric Emergency Department Wait Times. Pediatr Emerg Care 2022; 38:e929-e935. [PMID: 34140453 PMCID: PMC8671570 DOI: 10.1097/pec.0000000000002483] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES Wait time for emergency care is a quality measure that affects clinical outcomes and patient satisfaction. It is unknown if there is racial/ethnic variability in this quality measure in pediatric emergency departments (PEDs). We aim to determine whether racial/ethnic differences exist in wait times for children presenting to PEDs and examine between-site and within-site differences. METHODS We conducted a retrospective cohort study for PED encounters in 2016 using the Pediatric Emergency Care Applied Research Network Registry, an aggregated deidentified electronic health registry comprising 7 PEDs. Patient encounters were included among all patients 18 years or younger at the time of the ED visit. We evaluated differences in emergency department wait time (time from arrival to first medical evaluation) considering patient race/ethnicity as the exposure. RESULTS Of 448,563 visits, median wait time was 35 minutes (interquartile range, 17-71 minutes). Compared with non-Hispanic White (NHW) children, non-Hispanic Black (NHB), Hispanic, and other race children waited 27%, 33%, and 12% longer, respectively. These differences were attenuated after adjusting for triage acuity level, mode of arrival, sex, age, insurance, time of day, and month [adjusted median wait time ratios (95% confidence intervals): 1.11 (1.10-1.12) for NHB, 1.12 (1.11-1.13) for Hispanic, and 1.05 (1.03-1.06) for other race children compared with NHW children]. Differences in wait time for NHB and other race children were no longer significant after adjusting for clinical site. Fully adjusted median wait times among Hispanic children were longer compared with NHW children [1.04 (1.03-1.05)]. CONCLUSIONS In unadjusted analyses, non-White children experienced longer PED wait times than NHW children. After adjusting for illness severity, patient demographics, and overcrowding measures, wait times for NHB and other race children were largely determined by site of care. Hispanic children experienced longer within-site and between-site wait times compared with NHW children. Additional research is needed to understand structures and processes of care contributing to wait time differences between sites that disproportionately impact non-White patients.
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Affiliation(s)
- Tiffani J Johnson
- From the University of California, Davis Medical Center, Sacramento, CA
| | - Monika K Goyal
- Children's National Health System, The George Washington University, Washington, DC
| | - Scott A Lorch
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - James M Chamberlain
- Children's National Health System, The George Washington University, Washington, DC
| | - Lalit Bajaj
- University of Colorado, Children's Hospital, Aurora, CO
| | | | | | | | | | - Robert W Grundmeier
- Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, PA
| | - Elizabeth R Alpern
- Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University, Chicago, IL
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4
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Drendel AL, Brousseau DC, Casper TC, Bajaj L, Alessandrini EA, Grundmeier RW, Chamberlain JM, Goyal MK, Olsen CS, Alpern ER. Opioid Prescription Patterns at Emergency Department Discharge for Children with Fractures. Pain Med 2021; 21:1947-1954. [PMID: 32022894 DOI: 10.1093/pm/pnz348] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. DESIGN A retrospective cohort study of pediatric ED visits in 2015. SETTING Four pediatric EDs. SUBJECTS Children aged four to 18 years with a long-bone fracture discharged from the ED. METHODS A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. RESULTS There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9-9.7%), B = 12.1% (95% CI = 10.5-14.0%), C = 16.9% (95% CI = 15.2-18.8%), D = 23.8% (95% CI = 21.7-26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12-18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. CONCLUSIONS For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.
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Affiliation(s)
| | | | | | - Lalit Bajaj
- University of Colorado, Children's Hospital Colorado, Colorado
| | | | - Robert W Grundmeier
- University of Pennsylvania, Children's Hospital of Philadelphia, Pennsylvania
| | - James M Chamberlain
- Children's National Medical Center, The George Washington University, Washington, DC
| | - Monika K Goyal
- Children's National Medical Center, The George Washington University, Washington, DC
| | | | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago for The Pediatric Emergency Care Applied Research Network (PECARN), Chicago, Illinois, USA
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Reed JL, Alessandrini EA, Dexheimer J, Kachelmeyer A, Macaluso M, Zhang N, Kahn JA. Effectiveness of a Universally Offered Chlamydia and Gonorrhea Screening Intervention in the Pediatric Emergency Department. J Adolesc Health 2021; 68:57-64. [PMID: 33143985 PMCID: PMC7755827 DOI: 10.1016/j.jadohealth.2020.09.040] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 08/08/2020] [Accepted: 09/27/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE Adolescents represent more than half of the newly diagnosed sexually transmitted infections in the U.S. annually. Emergency departments (EDs) may serve as an effective, nontraditional setting to screen for chlamydia/gonorrhea (CT/GC). The objective was to evaluate the effectiveness of a universally offered CT/GC screening program in two pediatric ED settings. METHODS This was a prospective, delayed start pragmatic study conducted over 18 months in two EDs within the same academic institution among ED adolescents aged 14-21 years with any chief complaint. Using a tablet device, adolescents were confidentially informed of CT/GC screening recommendations and were offered screening. If patients agreed to CT/GC testing, a clinical decision support tool was triggered to inform the provider and order testing. The main and key secondary outcomes were the proportion of CT/GC testing and positive CT/GC test results in each respective ED. RESULTS Both EDs experienced modest but statistically significant increases in CT/GC testing post- versus pre-intervention (main: 11.5% vs. 7.9%; confidence interval [CI]: 2.9-4.2; p < .0001 and satellite: 3.8% vs. 2.6%; 95% CI: .7-1.7; p < .0001). Among those tested, the positivity rate at the main ED did not significantly change post- versus pre-intervention (24.1% vs. 23.2%; 95% CI: -1.9 to 3.8; p = .71) but significantly decreased at the satellite ED (7.6% vs. 14.8%; 95% CI: -12.2 to -2.2; p = .01). CONCLUSIONS A universally offered screening intervention increased the proportion of adolescents who were tested at both EDs and the detection rates for CT/GC at the main ED, but patient acceptance of screening was low.
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Affiliation(s)
- Jennifer L Reed
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Evaline A Alessandrini
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati Health System, Cincinnati, Ohio
| | - Judith Dexheimer
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Department of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Andrea Kachelmeyer
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Maurizio Macaluso
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Nanhua Zhang
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Jessica A Kahn
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Adolescent and Transition Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Zafar MA, Loftus TM, Palmer JP, Phillips M, Ko J, Ward SR, Foertsch M, Dalhover A, Doers ME, Mueller EW, Alessandrini EA, Panos RJ. COPD Care Bundle in Emergency Department Observation Unit Reduces Emergency Department Revisits. Respir Care 2020; 65:1-10. [PMID: 31882412 DOI: 10.4187/respcare.07088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND COPD exacerbations lead to accelerated decline in lung function, poor quality of life, and increased mortality and cost. Emergency department (ED) observation units provide short-term care to reduce hospitalizations and cost. Strategies to improve outcomes in ED observation units following COPD exacerbations are needed. We sought to reduce 30-d ED revisits for COPD exacerbations managed in ED observation units through implementation of a COPD care bundle. The study setting was an 800-bed, academic, safety-net hospital with 700 annual ED encounters for COPD exacerbations. Among those discharged from ED observation unit, the 30-d all-cause ED revisit rate (ie, the outcome measure) was 49% (baseline period: August 2014 through September 2016). METHODS All patients admitted to the ED observation unit with COPD exacerbations were included. A multidisciplinary team implemented the COPD bundle using iterative plan-do-study-act cycles with a goal adherence of 90% (process measure). The bundle, adopted from our inpatient program, was developed using care-delivery failures and unmet subject needs. It included 5 components: appropriate inhaler regimen, 30-d inhaler supply, education on devices available after discharge, standardized discharge instructions, and a scheduled 15-d appointment. We used statistical process-control charts for process and outcome measures. To compare subject characteristics and process features, we sampled consecutive patients from the baseline (n = 50) and postbundle (n = 83) period over 5-month and 7-month intervals, respectively. Comparisons were made using t tests and chi-square tests with P < .05 significance. RESULTS During baseline and postbundle periods, 410 and 165 subjects were admitted to the ED observation unit, respectively. After iterative plan-do-study-act cycles, bundle adherence reached 90% in 6 months, and the 30-d ED revisit rate declined from 49% to 30% (P = .003) with a system shift on statistical process-control charts. There was no difference in hospitalization rate from ED observation unit (45% vs 51%, P = .16). Subject characteristics were similar in the baseline and postbundle periods. CONCLUSIONS Reliable adherence to a COPD care bundle reduced 30-d ED revisits among those treated in the ED observation unit.
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Affiliation(s)
- Muhammad A Zafar
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.
| | - Timothy M Loftus
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jack P Palmer
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Michael Phillips
- Department of Respiratory Therapy, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Jonathan Ko
- Department of Respiratory Therapy, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Steven R Ward
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Madeline Foertsch
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Amber Dalhover
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Matthew E Doers
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Eric W Mueller
- Department of Pharmacy, University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Evaline A Alessandrini
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Ralph J Panos
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio.,Department of Medicine, Veterans Affairs Medical Center Cincinnati, Cincinnati, Ohio
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7
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Reed JL, Dexheimer JW, Kachelmeyer AM, Macaluso M, Alessandrini EA, Kahn JA. Information Technology-Assisted Screening for Gonorrhea and Chlamydia in a Pediatric Emergency Department. J Adolesc Health 2020; 67:186-193. [PMID: 32268995 PMCID: PMC7398829 DOI: 10.1016/j.jadohealth.2020.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 01/12/2020] [Accepted: 01/15/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE The aim of the study was to design and implement a novel, universally offered, computerized clinical decision support (CDS) gonorrhea and chlamydia (GC/CT) screening tool embedded in the emergency department (ED) clinical workflow and triggered by patient-entered data. METHODS The study consisted of the design and implementation of a tablet-based screening tool based on qualitative data of adolescent and parent/guardian acceptability of GC/CT screening in the ED and an advisory committee of ED leaders and end users. The tablet was offered to adolescents aged 14-21 years and informed patients of Centers for Disease Control and Prevention GC/CT screening recommendations, described the testing process, and assessed whether patients agreed to testing. The tool linked to CDS that streamlined the order entry process. The primary outcome was the patient capture rate (proportion of patients with tablet data recorded). The secondary outcomes included rates of patient agreement to GC/CT testing and provider acceptance of the CDS. RESULTS Outcomes at the main and satellite EDs, respectively, were as follows: 1-year patient capture rates were 64.6% and 64.5%; 9.9% and 4.4% of patients agreed to GC/CT testing, and of those, the provider ordered testing for 73% and 72%. CONCLUSIONS Implementation of this computerized screening tool embedded in the clinical workflow resulted in patient capture rates of almost two-thirds and clinician CDS acceptance rates >70% with limited patient agreement to testing. This screening tool is a promising method for confidential GC/CT screening among youth in an ED setting. Additional interventions are needed to increase adolescent agreement for GC/CT testing.
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Affiliation(s)
- Jennifer L. Reed
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Judith W. Dexheimer
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Biomedical Informatics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Andrea M. Kachelmeyer
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
| | - Evaline A. Alessandrini
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, US,University of Cincinnati Health System, Cincinnati, Ohio, US
| | - Jessica A. Kahn
- Division of Adolescent and Transition Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, US,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, US
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Zafar MA, Nguyen B, Gentene A, Ko J, Otten L, Panos RJ, Alessandrini EA. Pragmatic Challenge of Sustainability: Long-Term Adherence to COPD Care Bundle Maintains Lower Readmission Rate. Jt Comm J Qual Patient Saf 2019; 45:639-645. [DOI: 10.1016/j.jcjq.2019.05.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/26/2022]
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9
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Ballard DW, Kuppermann N, Vinson DR, Tham E, Hoffman JM, Swietlik M, Deakyne Davies SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Richards R, Casper TC, Goldberg HS, Grundmeier RW, Dayan PS. Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries. Ann Emerg Med 2019; 73:440-451. [DOI: 10.1016/j.annemergmed.2018.11.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Revised: 10/31/2018] [Accepted: 11/08/2018] [Indexed: 11/26/2022]
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Byczkowski TL, Downing KA, FitzGerald MR, Kennebeck SS, Gillespie GL, Alessandrini EA. The pediatric emergency department care experience: A quality measure. Patient Experience Journal 2018. [DOI: 10.35680/2372-0247.1288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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Gerhardt WE, Mara CA, Kudel I, Morgan EM, Schoettker PJ, Napora J, Britto MT, Alessandrini EA. Systemwide Implementation of Patient-Reported Outcomes in Routine Clinical Care at a Children's Hospital. Jt Comm J Qual Patient Saf 2018; 44:441-453. [PMID: 30071964 DOI: 10.1016/j.jcjq.2018.01.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/23/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Despite a growing literature on patient-reported outcomes (PROs), little has been written to guide development of a standardized, systemwide PRO program across multiple clinics and conditions. A PRO implementation program, which was created at Cincinnati Children's Hospital Medical Center, a large children's hospital, can serve as a standardized approach for the use of PROs in a clinical setting. METHODS Recommended standardized PRO implementation components include identification of a committed clinical leader and team, selection of an instrument that addresses the identified outcome of interest, specifying threshold scores that indicate when an intervention is needed, identification of clinical interventions to be triggered by threshold scores, provision of training for providers and staff involved in the PRO implementation process, and the measurement and monitoring of PRO use. RESULTS For each instrument, the completion goal is 80%, defined as the number of PRO measures that were actually completed divided by the number that should have been completed. The overall combined completion rate is 75% for the 68 unique instruments currently in use. Case studies of specific clinical team experiences demonstrate the value of using PROs and the implementation components and shows how PROs are used to promote patient-centered care. CONCLUSION Data on PRO implementation are collected on an ongoing basis to confirm the value of the program, define ongoing improvement, and fuel collaborative research to further refine essential implementation components and successful spread. Next steps include measuring the influence of PRO use on coproduction of patient-centered clinical care and the impact PRO measurement has on patient outcomes.
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Affiliation(s)
- Wendy E Gerhardt
- is Director, Quality Outcomes and Evidence, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center (CCHMC).
| | - Constance A Mara
- formerly Research Associate, James M. Anderson Center for Health Systems Excellence, is Quantitative Psychologist, Behavioral Medicine and Clinical Psychology, CCHMC, Department of Pediatrics, University of Cincinnati College of Medicine
| | - Ian Kudel
- formerly Research Associate, James M. Anderson Center for Health Systems Excellence, is Senior Scientist, QualityMetric Inc. (Optum)
| | - Esi M Morgan
- is Associate Professor, Rheumatology, James M. Anderson Center for Health Systems Excellence
| | | | - Jason Napora
- is Assistant Vice President, Information Services, CCHMC
| | - Maria T Britto
- is Professor of Pediatrics, Division of Adolescent and Transition Medicine, James M. Anderson Center for Health Systems Excellence
| | - Evaline A Alessandrini
- formerly Assistant Vice President of Improvement Integration and Assistant Professor, James M. Anderson Center for Health Systems Excellence, is Senior Vice President and Chief Medical Officer, University of Cincinnati Health System
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12
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Deakyne Davies SJ, Grundmeier RW, Campos DA, Hayes KL, Bell J, Alessandrini EA, Bajaj L, Chamberlain JM, Gorelick MH, Enriquez R, Casper TC, Scheid B, Kittick M, Dean JM, Alpern ER. The Pediatric Emergency Care Applied Research Network Registry: A Multicenter Electronic Health Record Registry of Pediatric Emergency Care. Appl Clin Inform 2018; 9:366-376. [PMID: 29791930 DOI: 10.1055/s-0038-1651496] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Electronic health record (EHR)-based registries allow for robust data to be derived directly from the patient clinical record and can provide important information about processes of care delivery and patient health outcomes. METHODS A data dictionary, and subsequent data model, were developed describing EHR data sources to include all processes of care within the emergency department (ED). ED visit data were deidentified and XML files were created and submitted to a central data coordinating center for inclusion in the registry. Automated data quality control occurred prior to submission through an application created for this project. Data quality reports were created for manual data quality review. RESULTS The Pediatric Emergency Care Applied Research Network (PECARN) Registry, representing four hospital systems and seven EDs, demonstrates that ED data from disparate health systems and EHR vendors can be harmonized for use in a single registry with a common data model. The current PECARN Registry represents data from 2,019,461 pediatric ED visits, 894,503 distinct patients, more than 12.5 million narrative reports, and 12,469,754 laboratory tests and continues to accrue data monthly. CONCLUSION The Registry is a robust harmonized clinical registry that includes data from diverse patients, sites, and EHR vendors derived via data extraction, deidentification, and secure submission to a central data coordinating center. The data provided may be used for benchmarking, clinical quality improvement, and comparative effectiveness research.
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Affiliation(s)
- Sara J Deakyne Davies
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado, United States
| | - Robert W Grundmeier
- Department of Pediatrics and Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Diego A Campos
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - Katie L Hayes
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Jamie Bell
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Evaline A Alessandrini
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado and Children's Hospital Colorado, Aurora, Colorado, United States
| | - James M Chamberlain
- Department of Pediatrics, Children's National Medical Center, Washington, District of Columbia, United States
| | - Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee Wisconsin, United States
| | - Rene Enriquez
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Beth Scheid
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Marlena Kittick
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, United States
| | - J Michael Dean
- Department of Pediatrics, University of Utah, Salt Lake City, Utah, United States
| | - Elizabeth R Alpern
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, United States
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13
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Goyal MK, Johnson TJ, Chamberlain JM, Casper TC, Simmons T, Alessandrini EA, Bajaj L, Grundmeier RW, Gerber JS, Lorch SA, Alpern ER. Racial and Ethnic Differences in Antibiotic Use for Viral Illness in Emergency Departments. Pediatrics 2017; 140:e20170203. [PMID: 28872046 PMCID: PMC5613999 DOI: 10.1542/peds.2017-0203] [Citation(s) in RCA: 110] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/02/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES In the primary care setting, there are racial and ethnic differences in antibiotic prescribing for acute respiratory tract infections (ARTIs). Viral ARTIs are commonly diagnosed in the pediatric emergency department (PED), in which racial and ethnic differences in antibiotic prescribing have not been previously reported. We sought to investigate whether patient race and ethnicity was associated with differences in antibiotic prescribing for viral ARTIs in the PED. METHODS This is a retrospective cohort study of encounters at 7 PEDs in 2013, in which we used electronic health data from the Pediatric Emergency Care Applied Research Network Registry. Multivariable logistic regression was used to examine the association between patient race and ethnicity and antibiotics administered or prescribed among children discharged from the hospital with viral ARTI. Children with bacterial codiagnoses, chronic disease, or who were immunocompromised were excluded. Covariates included age, sex, insurance, triage level, provider type, emergency department type, and emergency department site. RESULTS Of 39 445 PED encounters for viral ARTIs that met inclusion criteria, 2.6% (95% confidence interval [CI] 2.4%-2.8%) received antibiotics, including 4.3% of non-Hispanic (NH) white, 1.9% of NH black, 2.6% of Hispanic, and 2.9% of other NH children. In multivariable analyses, NH black (adjusted odds ratio [aOR] 0.44; CI 0.36-0.53), Hispanic (aOR 0.65; CI 0.53-0.81), and other NH (aOR 0.68; CI 0.52-0.87) children remained less likely to receive antibiotics for viral ARTIs. CONCLUSIONS Compared with NH white children, NH black and Hispanic children were less likely to receive antibiotics for viral ARTIs in the PED. Future research should seek to understand why racial and ethnic differences in overprescribing exist, including parental expectations, provider perceptions of parental expectations, and implicit provider bias.
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Affiliation(s)
- Monika K Goyal
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC;
| | - Tiffani J Johnson
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - James M Chamberlain
- Pediatrics and Emergency Medicine, Children's National Health System, The George Washington University, Washington, DC
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Timothy Simmons
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Evaline A Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lalit Bajaj
- Department of Pediatrics, University of Colorado, Children's Hospital, Boulder, Colorado; and
| | - Robert W Grundmeier
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeffrey S Gerber
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Scott A Lorch
- Department of Pediatrics, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Elizabeth R Alpern
- Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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14
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Zafar MA, Panos RJ, Ko J, Otten LC, Gentene A, Guido M, Clark K, Lee C, Robertson J, Alessandrini EA. Reliable adherence to a COPD care bundle mitigates system-level failures and reduces COPD readmissions: a system redesign using improvement science. BMJ Qual Saf 2017; 26:908-918. [PMID: 28733370 DOI: 10.1136/bmjqs-2017-006529] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 05/08/2017] [Accepted: 05/30/2017] [Indexed: 11/03/2022]
Abstract
BACKGROUND Readmissions of chronic obstructive pulmonary disease (COPD) have devastating effects on patient quality-of-life, disease progression and healthcare cost. Effective interventions to reduce COPD readmissions are needed. OBJECTIVES Reduce 30-day all-cause readmissions by (1) creating a COPD care bundle that addresses care delivery failures, (2) using improvement science to achieve 90% bundle adherence. SETTING An 800-bed academic hospital in Ohio, USA. The COPD 30-day all-cause readmission rate was 22.7% from August 2013 to September 2015. METHOD We performed a cross-sectional study of COPD 30-day readmissions from October 2014 to March 2015 to identify care delivery failures. We interviewed readmitted patients with COPD to identify their needs after discharge. A multidisciplinary team created a care bundle designed to mitigate system failures. Using a quasi-experimental study and 'Model for Improvement', we redesigned care delivery to improve bundle adherence. We used statistical process control charts to analyse bundle adherence and all-cause 30-day readmissions. RESULTS Cross-sectional review of the index (first-time) admissions revealed COPD was the most common readmission diagnosis and identified 42 system-level failures. The most prevalent failures were deficient inhaler regimen at discharge, late or non-existent follow-up appointments, and suboptimal discharge instructions. Patient interviews revealed confusing discharge instructions, especially regarding inhaler use. The COPD care-bundle components were: (1) appropriate inhaler regimen, (2) 30-day inhaler supply, (3) inhaler education on the device available postdischarge, (4) follow-up within 15 days (5) standardised patient-centred discharge instructions. The adherence to completing bundle components reached 90% in 5.5 months and was sustained. The COPD 30-day readmission rate decreased from 22.7% to 14.7%. Patients receiving all bundle components had a readmission rate of 10.9%. As a balancing measure for the targeted reduction in readmission rate, we assessed length of stay, which did not change (4.8 days before vs 4.6 days after; p=0.45). CONCLUSION System-level failures and unmet patient needs are modifiable risks for readmissions. Development and reliable implementation of a COPD care bundle that mitigates these failures reduced COPD readmissions.
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Affiliation(s)
- Muhammad Ahsan Zafar
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio, USA
| | - Ralph J Panos
- Division of Pulmonary and Critical Care Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA.,Department of Medicine, Cincinnati Veterans Affairs Medical Center, Cincinnati, Ohio, USA
| | - Jonathan Ko
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Lisa C Otten
- Department of Respiratory Care, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Anthony Gentene
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Maria Guido
- Division of Pharmacy Practice and Administration, University of Cincinnati James L Winkle College of Pharmacy, Cincinnati, Ohio, USA.,Department of Pharmacy Services, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Katherine Clark
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Caroline Lee
- Division of General Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jamie Robertson
- Division of Infectious Diseases, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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15
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Reed JL, Punches BE, Taylor RG, Macaluso M, Alessandrini EA, Kahn JA. A Qualitative Analysis of Adolescent and Caregiver Acceptability of Universally Offered Gonorrhea and Chlamydia Screening in the Pediatric Emergency Department. Ann Emerg Med 2017; 70:787-796.e2. [PMID: 28559031 DOI: 10.1016/j.annemergmed.2017.04.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE We qualitatively explore adolescent and parent or guardian attitudes about benefits and barriers to universally offered gonorrhea and chlamydia screening and modalities for assessing interest in screening in the pediatric emergency department (ED). METHODS A convenience sample of forty 14- to 21-year-olds and parents or guardians of adolescents presenting to an urban and community pediatric ED with any chief complaint participated in individual, semistructured, confidential interviews. Topics included support of universally offered gonorrhea and chlamydia screening, barriers and benefits to screening, and modalities for assessing interest in screening. Data were analyzed with framework analysis. RESULTS Almost all adolescents (37/40; 93%) and parents (39/40; 98%) support offering ED gonorrhea or chlamydia screening. Benefits included earlier diagnosis and treatment, convenience and transmission prevention (cited by both groups), and improved education and long-term health (cited by parents/guardians). Barriers included concerns about confidentiality and cost (cited by both groups), embarrassment (cited by adolescents), and nondisclosure to parents or guardians (cited by parents/guardians). Adolescents preferred that the request for gonorrhea or chlamydia screening be presented in a private room, using tablet technology. Both groups noted that the advantages to tablets included confidentiality and adolescents' familiarity with technology. Adolescents noted that tablet use would address concerns about bringing up gonorrhea or chlamydia screening with clinicians, whereas parents or guardians noted that tablets might increase screening incidence but expressed concern about the lack of personal interaction. CONCLUSION Universally offered gonorrhea and chlamydia screening in a pediatric ED was acceptable to the adolescents and parents or guardians in this study. Offering a tablet-based method to assess interest in screening may increase participation.
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Affiliation(s)
- Jennifer L Reed
- Division of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH.
| | - Brittany E Punches
- Cincinnati Children's Hospital Medical Center and Department of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Regina G Taylor
- Division of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH
| | - Maurizio Macaluso
- Division of Biostatistics and Epidemiology, University of Cincinnati Medical Center, Cincinnati, OH
| | - Evaline A Alessandrini
- Division of Emergency Medicine, University of Cincinnati Medical Center, Cincinnati, OH; James M. Anderson Center for Health Systems Excellence, University of Cincinnati Medical Center, Cincinnati, OH
| | - Jessica A Kahn
- Division of Adolescent and Transition Medicine, University of Cincinnati Medical Center, Cincinnati, OH
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16
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Dayan PS, Ballard DW, Tham E, Hoffman JM, Swietlik M, Deakyne SJ, Alessandrini EA, Tzimenatos L, Bajaj L, Vinson DR, Mark DG, Offerman SR, Chettipally UK, Paterno MD, Schaeffer MH, Wang J, Casper TC, Goldberg HS, Grundmeier RW, Kuppermann N. Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support. Pediatrics 2017; 139:peds.2016-2709. [PMID: 28341799 DOI: 10.1542/peds.2016-2709] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/24/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We determined whether implementing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) prediction rules and providing risks of clinically important TBIs (ciTBIs) with computerized clinical decision support (CDS) reduces computed tomography (CT) use for children with minor head trauma. METHODS Nonrandomized trial with concurrent controls at 5 pediatric emergency departments (PEDs) and 8 general EDs (GEDs) between November 2011 and June 2014. Patients were <18 years old with minor blunt head trauma. Intervention sites received CDS with CT recommendations and risks of ciTBI, both for patients at very low risk of ciTBI (no Pediatric Emergency Care Applied Research Network rule factors) and those not at very low risk. The primary outcome was the rate of CT, analyzed by site, controlling for time trend. RESULTS We analyzed 16 635 intervention and 2394 control patients. Adjusted for time trends, CT rates decreased significantly (P < .05) but modestly (2.3%-3.7%) at 2 of 4 intervention PEDs for children at very low risk. The other 2 PEDs had small (0.8%-1.5%) nonsignificant decreases. CT rates did not decrease consistently at the intervention GEDs, with low baseline CT rates (2.1%-4.0%) in those at very low risk. The control PED had little change in CT use in similar children (from 1.6% to 2.9%); the control GED showed a decrease in the CT rate (from 7.1% to 2.6%). For all children with minor head trauma, intervention sites had small decreases in CT rates (1.7%-6.2%). CONCLUSIONS The implementation of TBI prediction rules and provision of risks of ciTBIs by using CDS was associated with modest, safe, but variable decreases in CT use. However, some secular trends were also noted.
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Affiliation(s)
- Peter S Dayan
- Division of Emergency Medicine, Department of Pediatrics, Columbia University College of Physicians and Surgeons, New York, New York;
| | - Dustin W Ballard
- Kaiser Permanente, San Rafael Medical Center, San Rafael, California.,Division of Research, Kaiser Permanente, Oakland, California
| | - Eric Tham
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | | | - Marguerite Swietlik
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Sara J Deakyne
- Department of Research Informatics, Children's Hospital Colorado, Aurora, Colorado
| | - Evaline A Alessandrini
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Leah Tzimenatos
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
| | - Lalit Bajaj
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - David R Vinson
- Division of Research, Kaiser Permanente, Oakland, California.,Kaiser Permanente, Roseville Medical Center, Roseville, California
| | - Dustin G Mark
- Kaiser Permanente, Oakland Medical Center, Oakland, California
| | - Steve R Offerman
- Kaiser Permanente, South Sacramento Medical Center, Sacramento, California,
| | - Uli K Chettipally
- Kaiser Permanente, South San Francisco Medical Center, San Francisco, California
| | - Marilyn D Paterno
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Molly H Schaeffer
- Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Jun Wang
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - T Charles Casper
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Howard S Goldberg
- Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Information Systems, Partners HealthCare System, Boston, Massachusetts
| | - Robert W Grundmeier
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, University of California Davis School of Medicine, Sacramento, California
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17
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Byczkowski TL, Gillespie GL, Kennebeck SS, Fitzgerald MR, Downing KA, Alessandrini EA. Family-Centered Pediatric Emergency Care: A Framework for Measuring What Parents Want and Value. Acad Pediatr 2016; 16:327-35. [PMID: 26525991 DOI: 10.1016/j.acap.2015.08.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 08/19/2015] [Accepted: 08/22/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify and describe dimensions of family-centered care important to parents in pediatric emergency care and compare them to those currently defined in the literature. METHODS A qualitative study was conducted involving 8 focus groups with parents who accompanied their child to an emergency department visit at a large tertiary-care pediatric health system. Participants were identified using purposive sampling to achieve representation across demographic characteristics including child's race, insurance status, severity, and participant's relationship to child. Focus groups were segmented by patient age and presence of a chronic condition. They were moderated by a facilitator experienced in health-related topics. A 6-member multidisciplinary team completed a content analysis. RESULTS Sixty-eight parents participated. They were female (77%); aged 20 to 29 years (19%), 30 to 39 years (47%), more than 40 years (31%); black (44%), white (52%); and married (50%). Their child's characteristics were: public insurance (52%); black (46%), white (46%); and admitted as an inpatient (46%). The analysis resulted in 8 dimensions: 1) emotional support; 2) coordination; 3) elicit and respect preferences, and involve the patient and family in care decisions; 4) timely and attentive care; 5) information, communication, and education; 6) pain management; 7) safe and child-focused environment; and 8) continuity and transition. Compared to those published in the literature, the most notable differences were combining involving family and respect for preferences into a single dimension, and separating physical comfort into 2 dimensions: pain management and safe/child-focused environment. CONCLUSIONS The resulting dimensions provide a framework for measuring and improving the delivery of family-centered pediatric emergency care.
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Affiliation(s)
- Terri L Byczkowski
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
| | | | - Stephanie S Kennebeck
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michael R Fitzgerald
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kimberly A Downing
- Institute for Policy Research, University of Cincinnati, Cincinnati, Ohio
| | - Evaline A Alessandrini
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; James M. Anderson Center for Health Systems Excellence, Cincinnati, Ohio
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18
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Aronson PL, Williams DJ, Thurm C, Tieder JS, Alpern ER, Nigrovic LE, Schondelmeyer AC, Balamuth F, Myers AL, McCulloh RJ, Alessandrini EA, Shah SS, Browning WL, Hayes KL, Feldman EA, Neuman MI. Accuracy of diagnosis codes to identify febrile young infants using administrative data. J Hosp Med 2015; 10:787-93. [PMID: 26248691 PMCID: PMC4715646 DOI: 10.1002/jhm.2441] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/11/2015] [Accepted: 07/18/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development. OBJECTIVE Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants. DESIGN Retrospective cross-sectional study. SETTING Eight emergency departments in the Pediatric Health Information System. PATIENTS Infants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection. EXPOSURE The ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record. MEASUREMENTS Algorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values. RESULTS Among 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3). CONCLUSIONS A case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation.
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Affiliation(s)
- Paul L. Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Address correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-737-7443, Fax: 203-737-7447,
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Cary Thurm
- Children’s Hospital Association, Overland Park, KS
| | - Joel S. Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Amanda C. Schondelmeyer
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Fran Balamuth
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Angela L. Myers
- Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Russell J. McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Evaline A. Alessandrini
- James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Whitney L. Browning
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Katie L. Hayes
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elana A. Feldman
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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Affiliation(s)
- Evaline A Alessandrini
- Department of Pediatrics, James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joseph L Wright
- Department of Pediatrics and Child Health, Howard University College of Medicine, Washington, DC3Emergency Medicine and Health Policy, George Washington University School of Medicine and Health Sciences, and Milken Institute School of Public Health at the
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20
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Aronson PL, Thurm C, Williams DJ, Nigrovic LE, Alpern ER, Tieder JS, Shah SS, McCulloh RJ, Balamuth F, Schondelmeyer AC, Alessandrini EA, Browning WL, Myers AL, Neuman MI. Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age. J Hosp Med 2015; 10:358-65. [PMID: 25684689 PMCID: PMC4456211 DOI: 10.1002/jhm.2329] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Revised: 12/31/2014] [Accepted: 01/15/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN Retrospective cross-sectional study in 2013. SETTING Thirty-three hospitals in the Pediatric Health Information System. PATIENTS Infants aged ≤56 days with a diagnosis of fever. EXPOSURES The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.
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Affiliation(s)
- Paul L. Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Corresponding author Address correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-737-7443, Fax: 203-737-7447,
| | - Cary Thurm
- Children's Hospital Association, Overland Park, KS
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Joel S. Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Russell J. McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Fran Balamuth
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Amanda C. Schondelmeyer
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Evaline A. Alessandrini
- James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Whitney L. Browning
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Angela L. Myers
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, MA
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Fiks AG, Zhang P, Localio AR, Khan S, Grundmeier RW, Karavite DJ, Bailey C, Alessandrini EA, Forrest CB. Adoption of electronic medical record-based decision support for otitis media in children. Health Serv Res 2015; 50:489-513. [PMID: 25287670 PMCID: PMC4369219 DOI: 10.1111/1475-6773.12240] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVE Substantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence. STUDY SETTING A total of 41,391 OM visits with 108 clinicians at 16 pediatric practices between February 2009 and August 2010. STUDY DESIGN Prospective cohort study of EHR-based CDS adoption during OM visits, comparing clinicians receiving performance feedback to none. CDS was available to all physicians; use was voluntary. DATA COLLECTION Extraction from a common EHR. PRINCIPAL FINDINGS Clinicians and practices used the CDS system for a mean of 21 percent (range: 0-85 percent) and 17 percent (0-51 percent) of eligible OM visits, respectively. Clinicians who received performance feedback reports summarizing CDS use and guideline adherence had a relative increase in CDS use of 9.0 percentage points compared to others (p = .001). CDS adoption was associated with increased OM guideline adherence. Effects were greatest among clinicians with the lowest adherence prior to the study. CONCLUSIONS Performance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.
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Affiliation(s)
- Alexander G Fiks
- Address correspondence to Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia, 3535 Market Street, Room 1546, Philadelphia, PA 19104; e-mail:
| | - Peixin Zhang
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - A Russell Localio
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Saira Khan
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Robert W Grundmeier
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Dean J Karavite
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Charles Bailey
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Evaline A Alessandrini
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
| | - Christopher B Forrest
- Alexander G. Fiks, M.D., M.S.C.E., The Children's Hospital of Philadelphia3535 Market Street, Room 1546, Philadelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., is with the The Pediatric Research Consortium, PolicyLab, and the Center for Pediatric Clinical Effectiveness, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Peixin Zhang, Ph.D., and Christopher B. Forrest, M.D., Ph.D., are with the Division of General Pediatrics, The Children's Hospital of PhiladelphiaPhiladelphia, PA
- A. Russell Localio, Ph.D., is with the Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Saira Khan, M.P.H., is with the Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina-Chapel HillChapel Hill, NC
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., and Dean J. Karavite, M.S.I., are with the Center for Biomedical Informatics (CBMI), The Children's Hospital of PhiladelphiaPhiladelphia, PA
- Alexander G. Fiks, M.D., M.S.C.E., Robert W. Grundmeier, M.D., Charles Bailey, M.D., Ph.D., and Christopher B. Forrest, M.D., Ph.D., are also with the Department of Pediatrics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
- Evaline A. Alessandrini, M.D., M.S.C.E., is with the James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital Medical CenterCincinnati, OH
- Alexander G. Fiks, M.D., M.S.C.E., and Christopher B. Forrest, M.D., Ph.D., are with the Leonard Davis Institute of Health Economics, Perelman School of Medicine of the University of PennsylvaniaPhiladelphia, PA
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22
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Reed JL, Huppert JS, Gillespie GL, Taylor RG, Holland CK, Alessandrini EA, Kahn JA. Adolescent patient preferences surrounding partner notification and treatment for sexually transmitted infections. Acad Emerg Med 2015; 22:61-6. [PMID: 25545855 DOI: 10.1111/acem.12557] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/08/2014] [Accepted: 08/01/2014] [Indexed: 12/01/2022]
Abstract
OBJECTIVES Important barriers to addressing the sexually transmitted infection (STI) epidemic among adolescents are the inadequate partner notification of positive STI results and insufficient rates of partner testing and treatment. However, adolescent attitudes regarding partner notification and treatment are not well understood. The aim was to qualitatively explore the barriers to and preferences for partner notification and treatment among adolescent males and females tested for STIs in an emergency department (ED) setting and to explore the acceptability of ED personnel notifying their sexual partners. METHODS This was a descriptive, qualitative study in which a convenience sample of 40 adolescents (18 females, 22 males) 14 to 21 years of age who presented to either adult or pediatric EDs with STI-related complaints participated. Individualized, semistructured, confidential interviews were administered to each participant. Interviews were audiotaped and transcribed verbatim by an independent transcriptionist. Data were analyzed using framework analysis. RESULTS Barriers to partner notification included fear of retaliation or loss of the relationship, lack of understanding of or concern for the consequences associated with an STI, and social stigma and embarrassment. Participants reported two primary barriers to their partners obtaining STI testing and treatment: lack of transportation to the health care site and the partner's fear of STI positive test results. Most participants preferred to notify their main sexual partners of an STI exposure via a face-to-face interaction or a phone call. Most participants were agreeable with a health care provider (HCP) notifying their main sexual partners of STI exposure and preferred that the HCP notify the partner by phone call. CONCLUSIONS There are several adolescent preferences and barriers for partner notification and treatment. To be most effective, future interventions to prevent adolescent STIs should incorporate these preferences and address the barriers to partner notification. In an ED setting, using HCPs to provide partner notification of STI exposures is acceptable to adolescent patients; however, the feasibility of this type of program needs further exploration.
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Affiliation(s)
- Jennifer L. Reed
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Jill S. Huppert
- Division of Adolescent Gynecology; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | | | - Regina G. Taylor
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Carolyn K. Holland
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- Department of Emergency Medicine; University of Florida; Gainesville FL
| | - Evaline A. Alessandrini
- Division of Emergency Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
- The Anderson Center for Health Systems Excellence; Cincinnati Children's Hospital Medical Center; Cincinnati OH
| | - Jessica A. Kahn
- Division of Adolescent Medicine; Cincinnati Children's Hospital Medical Center; Cincinnati OH
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Reed JL, Huppert JS, Taylor RG, Gillespie GL, Byczkowski TL, Kahn JA, Alessandrini EA. Improving sexually transmitted infection results notification via mobile phone technology. J Adolesc Health 2014; 55:690-7. [PMID: 24962503 PMCID: PMC4209334 DOI: 10.1016/j.jadohealth.2014.05.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Revised: 05/08/2014] [Accepted: 05/09/2014] [Indexed: 11/17/2022]
Abstract
PURPOSE To improve adolescent notification of positive sexually transmitted infection (STI) tests using mobile phone technology and STI information cards. METHODS A randomized intervention among 14- to 21-year olds in a pediatric emergency department (PED). A 2 × 3 factorial design with replication was used to evaluate the effectiveness of six combinations of two factors on the proportion of STI-positive adolescents notified within 7 days of testing. Independent factors included method of notification (call, text message, or call + text message) and provision of an STI information card with or without a phone number to obtain results. Covariates for logistic regression included age, empiric STI treatment, days until first attempted notification, and documentation of confidential phone number. RESULTS Approximately half of the 383 females and 201 males enrolled were ≥18 years of age. Texting only or type of card was not significantly associated with patient notification rates, and there was no significant interaction between card and notification method. For females, successful notification was significantly greater for call + text message (odds ratio, 3.2; 95% confidence interval, 1.4-6.9), and documenting a confidential phone number was independently associated with successful notification (odds ratio, 3.6; 95% confidence interval, 1.7-7.5). We found no significant predictors of successful notification for males. Of patients with a documented confidential phone number who received a call + text message, 94% of females and 83% of males were successfully notified. CONCLUSIONS Obtaining a confidential phone number and using call + text message improved STI notification rates among female but not male adolescents in a pediatric emergency department.
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Affiliation(s)
- Jennifer L. Reed
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center Cincinnati, Oh, US
| | - Jill S. Huppert
- Division of Adolescent Gynecology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Oh, US
| | - Regina G. Taylor
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center Cincinnati, Oh, US
| | | | - Terri L. Byczkowski
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center Cincinnati, Oh, US
| | - Jessica A. Kahn
- Division of Adolescent Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Oh, US
| | - Evaline A. Alessandrini
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center Cincinnati, Oh, US
,The Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Oh, US
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Aronson PL, Thurm C, Alpern ER, Alessandrini EA, Williams DJ, Shah SS, Nigrovic LE, McCulloh RJ, Schondelmeyer A, Tieder JS, Neuman MI. Variation in care of the febrile young infant <90 days in US pediatric emergency departments. Pediatrics 2014; 134:667-77. [PMID: 25266437 DOI: 10.1542/peds.2014-1382] [Citation(s) in RCA: 176] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09). CONCLUSIONS Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.
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Affiliation(s)
- Paul L Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut;
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Samir S Shah
- Hospital Medicine, and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Russell J McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and
| | | | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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25
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Alpern ER, Clark AE, Alessandrini EA, Gorelick MH, Kittick M, Stanley RM, Michael Dean J, Teach SJ, Chamberlain JM. Recurrent and high-frequency use of the emergency department by pediatric patients. Acad Emerg Med 2014; 21:365-73. [PMID: 24730398 DOI: 10.1111/acem.12347] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 10/04/2013] [Accepted: 11/14/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The authors sought to describe the epidemiology of and risk factors for recurrent and high-frequency use of the emergency department (ED) by children. METHODS This was a retrospective cohort study using a database of children aged 0 to 17 years, inclusive, presenting to 22 EDs of the Pediatric Emergency Care Applied Research Network (PECARN) during 2007, with 12-month follow-up after each index visit. ED diagnoses for each visit were categorized as trauma, acute medical, or chronic medical conditions. Recurrent visits were defined as any repeat visit; high-frequency use was defined as four or more recurrent visits. Generalized estimating equations (GEEs) were used to measure the strength of associations between patient and visit characteristics and recurrent ED use. RESULTS A total of 695,188 unique children had at least one ED visit each in 2007, with 455,588 recurrent ED visits in the 12 months following the index visits. Sixty-four percent of patients had no recurrent visits, 20% had one, 8% had two, 4% had three, and 4% had four or more recurrent visits. Acute medical diagnoses accounted for most visits regardless of the number of recurrent visits. As the number of recurrent visits per patient rose, chronic diseases were increasingly represented, with asthma being the most common ED diagnosis. Trauma-related diagnoses were more common among patients without recurrent visits than among those with high-frequency recurrent visits (28% vs. 9%; p<0.001). High-frequency recurrent visits were more often within the highest severity score classifications. In multivariable analysis, recurrent visits were associated with younger age, black or Hispanic race or ethnicity, and public health insurance. CONCLUSIONS Risk factors for recurrent ED use by children include age, race and ethnicity, and insurance status. Although asthma plays an important role in recurrent ED use, acute illnesses account for the majority of recurrent ED visits.
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Affiliation(s)
- Elizabeth R. Alpern
- The Department of Pediatrics; Northwestern University Feinberg School of Medicine; Division of Emergency Medicine; Ann & Robert H. Lurie Children's Hospital of Chicago; Chicago IL
| | - Amy E. Clark
- The Department of Pediatrics; University of Utah; Salt Lake City UT
| | - Evaline A. Alessandrini
- The Department of Pediatrics; University of Cincinnati College of Medicine; James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine; Cincinnati Children's Hospital and Medical Center; Cincinnati OH
| | - Marc H. Gorelick
- The Department of Pediatrics; Medical College of Wisconsin; Children's Research Institute; Milwaukee WI
| | - Marlena Kittick
- The Division of Emergency Medicine; The Children's Hospital of Philadelphia; Philadelphia PA
| | - Rachel M. Stanley
- The Department of Emergency Medicine; The University of Michigan Medical Center; Ann Arbor MI
| | - J. Michael Dean
- The Department of Pediatrics; University of Utah; Salt Lake City UT
| | - Stephen J. Teach
- The Division of Emergency Medicine; Children's National Medical Center; Washington DC
| | - James M. Chamberlain
- The Division of Emergency Medicine; Children's National Medical Center; Washington DC
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Jain S, Cheng J, Alpern ER, Thurm C, Schroeder L, Black K, Ellison AM, Stone K, Alessandrini EA. Management of febrile neonates in US pediatric emergency departments. Pediatrics 2014; 133:187-95. [PMID: 24470644 DOI: 10.1542/peds.2013-1820] [Citation(s) in RCA: 76] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Blood, urine, and cerebrospinal fluid cultures and admission for antibiotics are considered standard management of febrile neonates (0-28 days). We examined variation in adherence to these recommendations across US pediatric emergency departments (PEDs) and incidence of serious infections (SIs) in febrile neonates. METHODS Cross-sectional study of neonates with a diagnosis of fever evaluated in 36 PEDs in the 2010 Pediatric Health Information System database. We analyzed performance of recommended management (laboratory testing, antibiotic use, admission to hospital), 48-hour return visits to PED, and diagnoses of SI. RESULTS Of 2253 neonates meeting study criteria, 369 (16.4%) were evaluated and discharged from the PED; 1884 (83.6%) were admitted. Recommended management occurred in 1497 of 2253 (66.4%; 95% confidence interval, 64.5-68.4) febrile neonates. There was more than twofold variation across the 36 PEDs in adherence to recommended management, recommended testing, and recommended treatment of febrile neonates. There was significant variation in testing and treatment between admitted and discharged neonates (P < .001). A total of 269 in 2253 (11.9%) neonates had SI, of whom 223 (82.9%; 95% confidence interval, 77.9-86.9) received recommended management. CONCLUSIONS There was wide variation across US PEDs in adherence to recommended management of febrile neonates. One in 6 febrile neonates was discharged from the PED; discharged patients were less likely to receive testing or antibiotic therapy than admitted patients. A majority of neonates with SI received recommended evaluation and management. High rates of SI in admitted patients but low return rates for missed infections in discharged patients suggest a need for additional studies to understand variation from the current recommendations.
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Affiliation(s)
- Shabnam Jain
- Emory University and Children's Healthcare of Atlanta, Atlanta, Georgia
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Kharbanda AB, Hall M, Shah SS, Freedman SB, Mistry RD, Macias CG, Bonsu B, Dayan PS, Alessandrini EA, Neuman MI. Variation in resource utilization across a national sample of pediatric emergency departments. J Pediatr 2013; 163:230-6. [PMID: 23332463 DOI: 10.1016/j.jpeds.2012.12.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Revised: 11/01/2012] [Accepted: 12/06/2012] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To describe variations in emergency department (ED) quality measures and determine the association between ED costs and outcomes for 3 pediatric conditions: asthma, gastroenteritis, and simple febrile seizure. STUDY DESIGN This cross-sectional analysis of ED visits used the Pediatric Health Information System database. Children aged ≤ 18 years who were evaluated in an ED between July 2009 and June 2011 and had a discharge diagnosis of asthma, gastroenteritis, or simple febrile seizure were included. Two quality of care metrics were evaluated for each target condition, and Spearman correlation was applied to evaluate the relationship between ED costs (reflecting overall resource utilization) and admission and revisit rates among institutions. RESULTS More than 250,000 ED visits at 21 member hospitals were analyzed. Among children with asthma, the median rate of chest radiography utilization was 35.1% (IQR, 31.3%-41.7%), and that of corticosteroid administration was 82.6% (IQR, 78.5%-86.5%). For children with gastroenteritis, the median rate of ondansetron administration was 52% (IQR, 43.2%-57.0%), and that of intravenous fluid administration was 18.1% (IQR, 15.3%-21.3%). Among children with febrile seizures, the median rate of computed tomography utilization was 3.1% (IQR, 2.7%-4.3%), and that of lumbar puncture was 4.0% (IQR, 2.3%-5.6%). Increased costs were not associated with lower admission rate or 3-day ED revisit rate for the 3 conditions. CONCLUSION We observed variation in quality measures for patients presenting to pediatric EDs with common conditions. Higher costs were not associated with lower hospitalization or ED revisit rates.
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Affiliation(s)
- Anupam B Kharbanda
- Department of Pediatric Emergency Medicine, Children's Hospitals and Clinics of Minnesota, Minneapolis, MN, USA.
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Forrest CB, Fiks AG, Bailey LC, Localio R, Grundmeier RW, Richards T, Karavite DJ, Elden L, Alessandrini EA. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics 2013; 131:e1071-81. [PMID: 23478860 DOI: 10.1542/peds.2012-1988] [Citation(s) in RCA: 71] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To assess the effects of electronic health record-based clinical decision support (CDS) and physician performance feedback on adherence to guidelines for acute otitis media (AOM) and otitis media with effusion (OME). METHODS We conducted a factorial-design cluster randomized trial with primary care practices (n = 24) as the unit of randomization and visits as the unit of analysis. Between December 2007 and September 2010, data were collected from 139,305 otitis media visits made by 55,779 children aged 2 months to 12 years. When activated, the CDS system provided guideline-based recommendations individualized to the patient's history and presentation. Monthly physician feedback reported adherence to guideline-based care, changes over time, and comparisons to others in the practice and network. RESULTS Comprehensive care (all recommended guidelines were adhered to) was accomplished for 15% of AOM and 5% of OME visits during the baseline period. The increase from baseline to intervention periods in adherence to guidelines was larger for CDS compared with non-CDS visits for comprehensive care, pain treatment, adequate diagnostic evaluation for OME, and amoxicillin as first-line therapy for AOM. Although performance feedback was associated with improved antibiotic prescribing for AOM and pain treatment, the joint effects of CDS and feedback on guideline adherence were not additive. There was marked variation in use of the CDS system, ranging from 5% to 45% visits across practices. CONCLUSIONS Clinical decision support and performance feedback are both effective strategies for improving adherence to otitis media guidelines. However, combining the 2 interventions is no better than either delivered alone.
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Affiliation(s)
- Christopher B Forrest
- Department of Pediatrics, Children's Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104, USA.
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Fiks AG, Mayne S, Localio AR, Feudtner C, Alessandrini EA, Guevara JP. Shared decision making and behavioral impairment: a national study among children with special health care needs. BMC Pediatr 2012; 12:153. [PMID: 22998626 PMCID: PMC3470977 DOI: 10.1186/1471-2431-12-153] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 09/17/2012] [Indexed: 11/30/2022] Open
Abstract
Background The Institute of Medicine has prioritized shared decision making (SDM), yet little is known about the impact of SDM over time on behavioral outcomes for children. This study examined the longitudinal association of SDM with behavioral impairment among children with special health care needs (CSHCN). Method CSHCN aged 5-17 years in the 2002-2006 Medical Expenditure Panel Survey were followed for 2 years. The validated Columbia Impairment Scale measured impairment. SDM was measured with 7 items addressing the 4 components of SDM. The main exposures were (1) the mean level of SDM across the 2 study years and (2) the change in SDM over the 2 years. Using linear regression, we measured the association of SDM and behavioral impairment. Results Among 2,454 subjects representing 10.2 million CSHCN, SDM increased among 37% of the population, decreased among 36% and remained unchanged among 27%. For CSHCN impaired at baseline, the change in SDM was significant with each 1-point increase in SDM over time associated with a 2-point decrease in impairment (95% CI: 0.5, 3.4), whereas the mean level of SDM was not associated with impairment. In contrast, among those below the impairment threshold, the mean level of SDM was significant with each one point increase in the mean level of SDM associated with a 1.1-point decrease in impairment (0.4, 1.7), but the change was not associated with impairment. Conclusion Although the change in SDM may be more important for children with behavioral impairment and the mean level over time for those below the impairment threshold, results suggest that both the change in SDM and the mean level may impact behavioral health for CSHCN.
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Affiliation(s)
- Alexander G Fiks
- The Pediatric Research Consortium (PeRC), The Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Fiks AG, Mayne S, Localio AR, Alessandrini EA, Guevara JP. Shared decision-making and health care expenditures among children with special health care needs. Pediatrics 2012; 129:99-107. [PMID: 22184653 PMCID: PMC3255469 DOI: 10.1542/peds.2011-1352] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN). METHODS We identified CSHCN <18 years in the 2002-2006 Medical Expenditure Panel Survey by using the CSHCN Screener. Outcomes included health care expenditures (total, out-of-pocket, office-based, inpatient, emergency department [ED], and prescription) and utilization (hospitalization, ED and office visit, and prescription rates). The main exposure was the pattern of SDM over the 2 study years (increasing, decreasing, or unchanged high or low). We assessed the impact of these patterns on the change in expenditures and utilization over the 2 study years. RESULTS Among 2858 subjects representing 12 million CSHCN, 15.9% had increasing, 15.2% decreasing, 51.9% unchanged high, and 17.0% unchanged low SDM. At baseline, mean per child total expenditures were $2131. Over the 2 study years, increasing SDM was associated with a decrease of $339 (95% confidence interval: $21, $660) in total health care costs. Rates of hospitalization and ED visits declined by 4.0 (0.1, 7.9) and 11.3 (4.3, 18.3) per 100 CSHCN, and office visits by 1.2 (0.3, 2.0) per child with increasing SDM. Relative to decreasing SDM, increasing SDM was associated with significantly lower total and out-of-pocket costs, and fewer office visits. CONCLUSIONS We found that increasing SDM was associated with decreased utilization and expenditures for CSHCN. Prospective study is warranted to confirm if fostering SDM reduces the costs of caring for CSHCN for the health system and families.
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Affiliation(s)
- Alexander G. Fiks
- The Pediatric Research Consortium (PeRC),Center for Biomedical Informatics (CBMI),Center for Pediatric Clinical Effectiveness,PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics
| | - Stephanie Mayne
- The Pediatric Research Consortium (PeRC),Center for Biomedical Informatics (CBMI),Center for Pediatric Clinical Effectiveness,PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Evaline A. Alessandrini
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - James P. Guevara
- The Pediatric Research Consortium (PeRC),Center for Pediatric Clinical Effectiveness,PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics
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Alessandrini EA, Alpern ER, Chamberlain JM, Shea JA, Holubkov R, Gorelick MH. Developing a diagnosis-based severity classification system for use in emergency medical services for children. Acad Emerg Med 2012; 19:70-8. [PMID: 22251193 DOI: 10.1111/j.1553-2712.2011.01250.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Lack of adequate risk adjustment methodologies has hindered the progress of emergency medicine health services research. The authors hypothesized that a consensus-derived, diagnosis-based severity classification system (SCS) would be significantly associated with actual measures of emergency department (ED) resource use and could ultimately be used to examine severity-adjusted outcomes across patient populations. METHODS A panel of subject matter experts used consensus methods to assign severity scores (1 = lowest severity to 5 = highest severity) to 3,041 ED International Classifications of Diseases (ICD), 9th revision, diagnosis codes. SCS scores were assigned to ED visits using the visit diagnosis code with the highest severity. We tested the association between the SCS scores and measures of ED resource use in three data sets: the Pediatric Emergency Care Applied Research Network Core Data Project (PCDP), the National Hospital Ambulatory Medical Care Survey (NHAMCS), and the Connecticut state ED data set. RESULTS There was a significant association between the five-level SCS and all six measures of resource use: triage category, disposition, ED resource use, Current Procedural Terminology Evaluation and Management (CPT E&M) codes, ED length of stay, and ED charges within the three ED data sets. CONCLUSIONS The SCS demonstrates validity in its strong association with actual ED resource use. The use of readily available ICD-9 diagnosis codes makes the SCS useful as a risk adjustment tool for health services research.
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Affiliation(s)
- Evaline A Alessandrini
- Department of Pediatrics, University of Cincinnati College of Medicine, James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Cincinnati Children's Hospital and Medical Center, Cincinnati, OH, USA.
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Abstract
OBJECTIVES To characterize patterns of electronic medical record (EMR) use at pediatric primary care acute visits. DESIGN Direct observational study of 529 acute visits with 27 experienced pediatric clinician users. MEASUREMENTS For each 20 s interval and at each stage of the visit according to the Davis Observation Code, we recorded whether the physician was communicating with the family only, using the computer while communicating, or using the computer without communication. Regression models assessed the impact of clinician, patient and visit characteristics on overall visit length, time spent interacting with families, and time spent using the computer while interacting. RESULTS The mean overall visit length was 11:30 (min:sec) with 9:06 spent in the exam room. Clinicians used the EMR during 27% of exam room time and at all stages of the visit (interacting, chatting, and building rapport; history taking; formulation of the diagnosis and treatment plan; and discussing prevention) except the physical exam. Communication with the family accompanied 70% of EMR use. In regression models, computer documentation outside the exam room was associated with visits that were 11% longer (p=0.001), and female clinicians spent more time using the computer while communicating (p=0.003). LIMITATIONS The 12 study practices shared one EMR. CONCLUSIONS Among pediatric clinicians with EMR experience, conversation accompanies most EMR use. Our results suggest that efforts to improve EMR usability and clinician EMR training should focus on use in the context of doctor-patient communication. Further study of the impact of documentation inside versus outside the exam room on productivity is warranted.
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Affiliation(s)
- Alexander G Fiks
- The Pediatric Research Consortium (PeRC), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Abstract
OBJECTIVES To identify patterns of shared decision-making (SDM) among a nationally representative sample of US children with attention-deficit/hyperactivity disorder (ADHD) or asthma and determine if demographics, health status, or access to care are associated with SDM. PATIENTS AND METHODS We performed a cross-sectional study of the 2002-2006 Medical Expenditure Panel Survey, which represents 2 million children with ADHD and 4 million children with asthma. The outcome, high SDM, was defined by using latent class models based on 7 Medical Expenditure Panel Survey items addressing aspects of SDM. We entered factors potentially associated with SDM into logistic regression models with high SDM as the outcome. Marginal standardization then described the standardized proportion of children's households with high SDM for each factor. RESULTS For both ADHD and asthma, 65% of children's households had high SDM. Those who reported poor general health for their children were 13% less likely to have high SDM for ADHD (64 vs 77%) and 8% less likely for asthma (62 vs 70%) when adjusting for other factors. Results for behavioral impairment were similar. Respondent demographic characteristics were not associated with SDM. Those with difficulty contacting their clinician by telephone were 26% (ADHD: 55 vs 81%) and 29% (asthma: 48 vs 77%) less likely to have high SDM than those without difficulty. CONCLUSIONS These findings indicate that households of children who report greater impairment or difficulty contacting their clinician by telephone are less likely to fully participate in SDM. Future research should examine how strategies to foster ongoing communication between families and clinicians affect SDM.
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Affiliation(s)
- Alexander G. Fiks
- Pediatric Research Consortium, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Pediatric Generalist Research Group, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania,Center for Biomedical Informatics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - A. Russell Localio
- Department of Biostatistics and Epidemiology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Evaline A. Alessandrini
- Divisions of Health Policy and Clinical Effectiveness and Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - David A. Asch
- Leonard Davis Institute of Health Economics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania,Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - James P. Guevara
- Pediatric Research Consortium, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Pediatric Generalist Research Group, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania,Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Topjian AA, Localio AR, Berg RA, Alessandrini EA, Meaney PA, Pepe PE, Larkin GL, Peberdy MA, Becker LB, Nadkarni VM. Women of child-bearing age have better inhospital cardiac arrest survival outcomes than do equal-aged men. Crit Care Med 2010; 38:1254-60. [PMID: 20228684 DOI: 10.1097/ccm.0b013e3181d8ca43] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Estrogen and progesterone improve neurologic outcomes in experimental models of cardiac arrest and stroke. Our objective was to determine whether women of child-bearing age are more likely than men to survive to hospital discharge after in-hospital cardiac arrest. DESIGN Prospective, observational study. SETTING Five hundred nineteen hospitals in the National Registry of Cardiopulmonary Resuscitation database. PATIENTS Patients included 95,852 men and women 15-44 yrs and 56 yrs or older with pulseless cardiac arrests from January 1, 2000 through July 31, 2008. MEASUREMENTS AND MAIN RESULTS Patients were stratified a priori by gender and age groups (15-44 yrs and > or =56 yrs). Fixed-effects regression conditioning on hospital was used to examine the relationship between age, gender, and survival outcomes. The unadjusted survival to discharge rate for younger women of child-bearing age (15-44 yrs) was 19% (940/4887) vs. 17% (1203/7025) for younger men (p = .013). The adjusted hospital discharge difference between these younger women and men was 2.8% (95% confidence interval, 1.0% to 4.6%; p = .002), and these younger women also had a 2.6% (95% confidence interval, 0.9% to 4.3%; p = .002) absolute increase in favorable neurologic outcome. For older women compared with men (> or =56 yrs), there were no demonstrable differences in discharge rates (18% vs. 18%; adjusted difference, -0.1%; 95% confidence interval, -0.9% to 0.6%; p = .68) or favorable neurologic outcome (14% vs. 14%; adjusted difference, -0.1%; 95% confidence interval, -0.7% to 0.5%; p = .74). CONCLUSIONS Women of child-bearing age were more likely than comparably aged men to survive to hospital discharge after in-hospital cardiac arrest, even after controlling for etiology of arrest and other important variables.
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Affiliation(s)
- Alexis A Topjian
- Department of Anesthesia and Critical Care Medicine, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Abstract
OBJECTIVES A clinically sensible system of grouping diseases is needed for describing pediatric emergency diagnoses for research and reporting. This project aimed to create an International Classification of Diseases (ICD)-based diagnosis grouping system (DGS) for child emergency department (ED) visits that is 1) clinically sensible with regard to how diagnoses are grouped and 2) comprehensive in accounting for nearly all diagnoses (>95%). The second objective was to assess the construct validity of the DGS by examining variation in the frequency of targeted groups of diagnoses within the concepts of season, age, sex, and hospital type. METHODS A panel of general and pediatric emergency physicians used the nominal group technique and Delphi surveys to create the DGS. The primary data source used to develop the DGS was the Pediatric Emergency Care Applied Research Network (PECARN) Core Data Project (PCDP). RESULTS A total of 3,041 ICD-9 codes, accounting for 98.9% of all diagnoses in the PCDP, served as the basis for creation of the DGS. The expert panel developed a DGS framework representing a clinical approach to the diagnosis and treatment of pediatric emergency patients. The resulting DGS has 21 major groups and 77 subgroups and accounts for 96.5% to 99% of diagnoses when applied to three external data sets. Variations in the frequency of targeted groups of diagnoses related to seasonality, age, sex, and site of care confirm construct validity. CONCLUSIONS The DGS offers a clinically sensible method for describing pediatric ED visits by grouping ICD-9 codes in a consensus-derived classification scheme. This system may be used for research, reporting, needs assessment, and resource planning.
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Affiliation(s)
- Evaline A Alessandrini
- Department of Pediatrics, University of Pennsylvania School of Medicine and Emergency Medicine, The Children's Hospital of Philadelphia, PA, USA.
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Fiks AG, Hunter KF, Localio AR, Grundmeier RW, Bryant-Stephens T, Luberti AA, Bell LM, Alessandrini EA. Impact of electronic health record-based alerts on influenza vaccination for children with asthma. Pediatrics 2009; 124:159-69. [PMID: 19564296 DOI: 10.1542/peds.2008-2823] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma. METHODS A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices. RESULTS A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.3% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (>or=11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits. CONCLUSIONS Clinical alerts were associated with only modest improvements in influenza vaccination rates.
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Affiliation(s)
- Alexander G Fiks
- Pediatric Generalist Research Group, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Gorelick MH, Knight S, Alessandrini EA, Stanley RM, Chamberlain JM, Kuppermann N, Alpern ER. Lack of Agreement in Pediatric Emergency Department Discharge Diagnoses from Clinical and Administrative Data Sources. Acad Emerg Med 2008. [DOI: 10.1111/j.1553-2712.2007.tb01852.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
OBJECTIVE We assessed the impact of immunization at sick visits on subsequent and overall well-child care. METHODS We performed a retrospective cohort study using electronic health record data from 4 urban practices affiliated with an academic medical center. Participants included all children born between September 1, 2003, and July 31, 2004, with a visit at a study practice before 6 weeks of age and > or = 1 sick visit (n = 1675). The main outcome measures were (1) attendance at a well-child visit within 60 days after an index sick visit by children due for vaccines and preventive care and (2) the overall number of well-child visits kept by children between 6 weeks and 13 months of age. RESULTS Among all demographic and health-related factors considered, immunization receipt at a sick visit was associated most strongly with decreased subsequent well-child care. Among children already delayed (late) for vaccines, 31% returned for well-child care if immunizations were given at eligible sick visits, compared with 47% of those who received no vaccines (risk difference, with adjustment for covariates: -16%). Among those without immunization delay, 42% of children who received vaccines returned for well-child care, compared with 73% of those who received no vaccines (risk difference: -31%). Although 5 well-child visits are recommended, children with no immunizations at sick visits had an adjusted predicted number of 3.8 well-child visits, those with 1 sick visit with immunizations had 3.3 visits, and those with > or = 2 sick visits with immunizations had 2.8 visits between 6 weeks and 13 months of age. CONCLUSIONS Immunization at sick visits was associated with decreased rates of well-child care, especially among those without previous vaccine delay. This strong association between immunization at sick visits and well-child care should be considered in any plan to restructure pediatric preventive care.
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Affiliation(s)
- Alexander G Fiks
- Pediatric Research Consortium, Children's Hospital of Philadelphia, 3535 Market St, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVES The goals were (1) to examine the influence of continuity of care on delivery of lead, anemia, and tuberculosis screening in a cohort of Medicaid-enrolled children, (2) to determine whether well-child care continuity had a greater effect than continuity for all ambulatory visits, and (3) to investigate which aspects of continuity were most associated with receipt of these screening services. METHODS A prospective birth cohort of 1564 Medicaid-enrolled infants was studied. Continuity of care scores for the first 6 months of life were calculated for total ambulatory visits and well-child care visits. Outcomes of interest were performance of > or = 1 screening for lead toxicity, anemia, and tuberculosis during the first 24 months of life. RESULTS For total ambulatory visits, children with complete continuity of care (the same practitioner seen for every visit) were more than twice as likely to receive lead screening, compared with children who saw a different practitioner for every visit, irrespective of the measurement technique used. Similarly, children with complete continuity were 1.5 to 2 times more likely to have been screened for tuberculosis. Continuity showed a lesser, but still significant, effect on anemia screening. Well-child care visit continuity of care had less impact on screening performance than did total visit continuity of care. CONCLUSIONS In this study, greater continuity of care in infancy was associated with increased likelihood of receiving screening for lead toxicity, anemia, and tuberculosis in the first 24 months of life. The dimension of continuity of care that was most influential in this population was dispersion of visits among different practitioners.
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Affiliation(s)
- Ana I Flores
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania School of Medicine, Philadelphia, PA 19104, USA
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Fiks AG, Grundmeier RW, Biggs LM, Localio AR, Alessandrini EA. Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population. Pediatrics 2007; 120:707-14. [PMID: 17908756 DOI: 10.1542/peds.2007-0257] [Citation(s) in RCA: 113] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The objective of this study was to test the hypothesis that clinical alerts for routine pediatric vaccinations within an electronic health record would reduce missed opportunities for vaccination and improve immunization rates for young children in an inner-city population. METHODS A 1-year intervention study (September 1, 2004, to August 31, 2005) with historical controls was conducted in 4 urban primary care centers affiliated with an academic medical center. All children who were younger than 24 months were enrolled. Electronic health record-based clinical reminders for routine childhood vaccinations were programmed to appear prominently at every patient encounter with vaccines due. The main outcome measures were rates of captured immunization opportunities and overall immunization rates at 24 months of age. RESULTS Immunization alerts appeared at 15,928 visits during the intervention. Alert implementation was associated with increases in captured immunization opportunities from 78.2% to 90.3% at well visits and from 11.3% to 32.0% at sick visits. Adjusted up-to-date immunization rates at 24 months of age increased from 81.7% to 90.1% from the control to intervention period. Children in the intervention group also became up-to-date earlier than control patients. Patient characteristics were stable throughout the study. CONCLUSIONS An electronic health record-based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.
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Affiliation(s)
- Alexander G Fiks
- Pediatric Research Consortium, Children's Hospital of Philadelphia, 3535 Market St, Room 1546, Philadelphia, PA 19104, USA.
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Gorelick MH, Knight S, Alessandrini EA, Stanley RM, Chamberlain JM, Kuppermann N, Alpern ER. Lack of agreement in pediatric emergency department discharge diagnoses from clinical and administrative data sources. Acad Emerg Med 2007; 14:646-52. [PMID: 17554009 DOI: 10.1197/j.aem.2007.03.1357] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Diagnosis information from existing data sources is used commonly for epidemiologic, administrative, and research purposes. The quality of such data for emergency department (ED) visits is unknown. OBJECTIVES To determine the agreement on final diagnoses between two sources, electronic administrative sources and manually abstracted medical records, for pediatric ED visits, in a multicenter network. METHODS This was a cross sectional study at 19 EDs nationwide. The authors obtained data from two sources at each ED during a three-month period in 2003: administrative sources for all visits and abstracted records for randomly selected visits during ten days over the study period. Records were matched using unique identifiers and probabilistic linkage. The authors recorded up to three diagnoses from each abstracted medical record and up to ten for the administrative data source. Diagnoses were grouped into 104 groups using a modification of the Clinical Classification System. RESULTS A total of 8,860 abstracted records had at least one valid diagnosis code (with a total of 12,895 diagnoses) and were successfully matched to records in the administrative source. Overall, 67% (95% confidence interval = 66% to 68%) of diagnoses from the administrative and abstracted sources were within the same diagnosis group. Agreement varied by site, ranging from 54% to 77%. Agreement varied substantially by diagnosis group; there was no difference by method of linkage. Clustering clinically similar diagnosis groups improved agreement between administrative and abstracted data sources. CONCLUSIONS ED diagnoses retrieved from electronic administrative sources and manual chart review frequently disagree, even if similar diagnosis codes are grouped. Agreement varies by institution and by diagnosis. Further work is needed to improve the accuracy of diagnosis coding; development of a grouping system specific to pediatric emergency care may be beneficial.
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Affiliation(s)
- Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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Gorelick MH, Alessandrini EA, Cronan K, Shults J. Revised Pediatric Emergency Assessment Tool (RePEAT): a severity index for pediatric emergency care. Acad Emerg Med 2007; 14:316-23. [PMID: 17312335 DOI: 10.1197/j.aem.2006.11.015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To develop and validate a multivariable model, using information available at the time of patient triage, to predict the level of care provided to pediatric emergency patients for use as a severity of illness measure. METHODS This was a retrospective cohort study of 5,521 children 18 years of age or younger treated at four emergency departments (EDs) over a 12-month period. Data were obtained from abstraction of patient records. Logistic regression was used to develop (75% of sample) and validate (25% of sample) models to predict any nonroutine diagnostic or therapeutic intervention in the ED and admission to the hospital. Data on ED length of stay and hospital costs were also obtained. RESULTS Eight predictor variables were included in the final models: presenting complaint, age, triage acuity category, arrival by emergency medical services, current use of prescription medications, and three triage vital signs (heart rate, respiratory rate, and temperature). The resulting models had adequate goodness of fit in both derivation and validation samples. The area under the receiver operating characteristic curve was 0.73 for the ED intervention model and 0.85 for the admission model. The Revised Pediatric Emergency Assessment Tool (RePEAT) score was then calculated as the sum of the predicted probability of receiving intervention and twice the predicted probability of admission. The RePEAT score had a significant univariate association with ED costs (r = 0.44) and with ED length of stay (r = 0.27) and contributed significantly to the fit of multivariable models comparing these outcomes across sites. CONCLUSIONS The RePEAT score accurately predicts level of care provided for pediatric emergency patients and may provide a useful means of risk adjustment when benchmarking outcomes
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Affiliation(s)
- Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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Mistry RD, Cho CS, Bilker WB, Brousseau DC, Alessandrini EA. Categorizing urgency of infant emergency department visits: agreement between criteria. Acad Emerg Med 2006; 13:1304-11. [PMID: 17099192 DOI: 10.1197/j.aem.2006.07.028] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization. OBJECTIVES To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits. METHODS This was a secondary data analysis of a prospective birth cohort of Medicaid-enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (kappa) between the implicit criteria and alternative methods were measured. RESULTS A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD +/- 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (kappa = 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (kappa = 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (kappa = 0.35 and kappa = 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent. CONCLUSIONS The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available.
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Affiliation(s)
- Rakesh D Mistry
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, USA.
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Fiks AG, Alessandrini EA, Luberti AA, Ostapenko S, Zhang X, Silber JH. Identifying factors predicting immunization delay for children followed in an urban primary care network using an electronic health record. Pediatrics 2006; 118:e1680-6. [PMID: 17088398 DOI: 10.1542/peds.2005-2349] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE An opportunity exists to use increasingly prevalent electronic health records to efficiently gather immunization, clinical, and demographic data to assess and subsequently reduce barriers to immunization. The objective of this study was to use data entered at the point of care within an electronic health record to identify factors that predispose children in an inner-city population to immunization delay. METHODS Retrospective cohort data from an electronic health record were used to evaluate the association between demographic, clinical, and immunization variables on immunization delay at 24 months. Patients 2 to 5 years old as of May 31, 2003, with an office visit between May 31, 2002, and May 31, 2003, were selected (N = 5464). Univariate and multivariable models were developed to predict vaccination delay at 24 months per the Advisory Committee on Immunization Practices guidelines. RESULTS Overall up-to-date immunization rates at 3, 7, 13, and 24 months were 75%, 45%, 82%, and 71%. Multivariable models using electronic health record data showed that early immunization status was the strongest predictor of immunization delay at 24 months. Multivariate analysis revealed that children who were inadequately immunized at 3 months of age were more than 4.5 times as likely to be immunization delayed at 24 months. In this analysis, patient and caregiver factors associated with immunization delay included insurance status and nonparent caregiver. Children who were premature were less likely to be delayed. CONCLUSIONS Using an electronic health record with information entered at the point of care, we found that early immunization status is a strong predictor of immunization delay for young children that can be identified as early as 3 months of age. Electronic health records may prove useful to clinicians and health systems in identifying children at high risk for immunization delay.
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Affiliation(s)
- Alexander G Fiks
- Pediatric Research Consortium, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVE Between 20% and 80% of emergency department (ED) visits are nonurgent. This variability in estimates is partially due to the multiple classification methods used, none of which has undergone validity or reliability testing. Our objectives were to determine the methods thought to be most valid and to understand expert perceptions of nonurgent ED utilization. METHODS A survey of the Pediatric Emergency Medicine (PEM) Special Interest Group at the 2005 Pediatric Academic Societies meeting was conducted. An education session with case-based discussion for categorizing ED visit urgency was presented. Six methods were reviewed: implicit criteria, explicit criteria, resource utilization, diagnoses, Current Procedural Terminology Codes, and nurse triage category. The primary outcome was the percentage of respondents ranking each method first or second best for categorizing urgency. Respondents also identified ED resources and presenting symptoms constituting an urgent visit. RESULTS Seventy-four percent of attendees completed the survey, most were Pediatric Emergency Medicine physicians. Implicit criteria were rated highest, with 65.1% ranking it first or second, followed by explicit criteria (53.8%). With limited data available, resource utilization ranked highest (68.6%), followed by nurse triage (61.2%). There was an agreement that certain presenting symptoms and resources were adequate for determining ED visit urgency; however, there was no agreement on whether x-rays, urinalyses, or fever in a child older than 3 months was sufficient to identify urgency. CONCLUSIONS Methods using complete medical record information are favored to determine ED visit urgency. Resource utilization and nurse triage are preferred when limited data are available. This survey will serve as the basis for endorsement of methodologically sound criteria for ED visit urgency.
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Affiliation(s)
- David C Brousseau
- Department of Pediatrics, Section of Emergency Medicine and the Children's Research Institute, Medical College of Wisconsin, Milwaukee, WI, USA.
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Jacobstein CR, Alessandrini EA, Lavelle JM, Shaw KN. Unscheduled revisits to a pediatric emergency department: risk factors for children with fever or infection-related complaints. Pediatr Emerg Care 2005; 21:816-21. [PMID: 16340756 DOI: 10.1097/01.pec.0000190228.97362.30] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Unscheduled revisits (URVs) may serve as markers of quality of care and may be costly both in financial terms as well as in limitations they place on primary care. We performed this study to examine the association between characteristics easily obtainable during an emergency department (ED) visit and URV to identify a subpopulation of children who may warrant interventions to decrease URV. METHODS This is a case-control study of patients visiting an urban tertiary care pediatric ED for a fever or infectious disease-related complaint. Cases were defined as patients who had URVs that occurred within 72 hours of an initial ED visit. Control patients were selected by simple random sampling of an enumerated computerized list of all ED visits. Data on independent variables of interest were collected from a chart review and telephone interview with the patient's caregiver. Bivariate and multivariate analyses were performed to determine factors associated with URV. RESULTS Seventy-five percent of cases and controls participated in the study. Logistic regression analysis revealed 3 factors independently associated with URV for fever or infectious disease-related complaints in children. These included presence of chronic disease (adjusted odds ratio 1.75, 95% confidence interval 1.01-3.03), Medicaid insurance (adjusted odds ratio 1.86, 95% confidence interval 1.04-3.32) and acute triage category (adjusted odds ratio 1.83, 95% confidence interval 1.08-3.10). CONCLUSIONS These factors may be used to identify children in the ED at greater risk for URV and may point to a need for improved discharge instructions and enhanced communication with primary care and systems to arrange follow-up. Results of this work may also identify at-risk populations for future qualitative research or intervention studies on URV to EDs.
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Affiliation(s)
- Cynthia R Jacobstein
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, PA 19104, USA
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Friedlaender EY, Rubin DM, Alpern ER, Mandell DS, Christian CW, Alessandrini EA. Patterns of health care use that may identify young children who are at risk for maltreatment. Pediatrics 2005; 116:1303-8. [PMID: 16322151 DOI: 10.1542/peds.2004-1988] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children. METHODS We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non-emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child's primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities. RESULTS We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40-4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96-24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints. CONCLUSIONS Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.
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Affiliation(s)
- Eron Y Friedlaender
- Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
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Abstract
OBJECTIVES To develop a set of chief complaint groupings for pediatric emergency department (ED) visits that is comprehensive, parsimonious, clinically sensible, and evidence-based. METHODS Investigators derived candidate chief complaint clusters and ranked them a priori into three perceived severity categories. Pediatric visits were extracted from the National Hospital Ambulatory Medical Care Survey (NHAMCS); data for years 1998 and 2000 (n = 13,186) were used for derivation and data for year 1999 (n = 5,365) were used for validation. Visits were assigned to clusters based on the recorded complaints; clusters were combined to ensure adequate numbers for analysis (minimum n = 20), and the clusters were reviewed for clinical sensibility. Resource utilization was categorized in three levels: routine (examination only), ED treatment (tests or therapy in the ED but not admitted), and admission. Area under the receiver-operating characteristic (ROC) curve (AUC) was used to demonstrate the discriminative ability of the clusters in predicting resource use. RESULTS There were 463 unique complaints in the derivation database; 95 (20%) had a single associated visit. Fifty-two clusters were generated; only 2.4% of complaints were classified as other. The eight most common clusters encompassed 52% of the visits. The top five were fever (11%), extremity pain/injury, vomiting, cough, and trauma (unspecified). Complaint clusters were associated with actual resource utilization: for routine care, the AUC was 0.73 (0.74 in the validation set), and for admission, the AUC was 0.77 (0.74 in the validation set). Both resource utilization and triage classification increased with increased expert severity ranking (test for trend, p < 0.001). CONCLUSIONS The proposed Pediatric Emergency Reason for Visit Cluster (PERC) system is a comprehensive yet parsimonious, clinically sensible means of categorizing pediatric ED complaints. The PERC system's association with measures of acuity and resource utilization makes it a potentially useful tool in epidemiologic and health services research.
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Affiliation(s)
- Marc H Gorelick
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI, USA.
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Abstract
BACKGROUND Prior research identified foster care children using Medicaid eligibility codes specific to foster care, but it is unknown whether these codes capture all foster care children. OBJECTIVES To describe the sampling bias in relying on Medicaid eligibility codes to identify foster care children. METHODS Using foster care administrative files linked to Medicaid data, we describe the proportion of children whose Medicaid eligibility was correctly encoded as foster child during a 1-year follow-up period following a new episode of foster care. Sampling bias is described by comparing claims in mental health, emergency department (ED), and other ambulatory settings among correctly and incorrectly classified foster care children. RESULTS Twenty-eight percent of the 5683 sampled children were incorrectly classified in Medicaid eligibility files. In a multivariate logistic regression model, correct classification was associated with duration of foster care (>9 vs <2 months, odds ratio [OR] 7.67, 95% confidence interval [CI] 7.17-7.97), number of placements (>3 vs 1 placement, OR 4.20, 95% CI 3.14-5.64), and placement in a group home among adjudicated dependent children (OR 1.87, 95% CI 1.33-2.63). Compared with incorrectly classified children, correctly classified foster care children were 3 times more likely to use any services, 2 times more likely to visit the ED, 3 times more likely to make ambulatory visits, and 4 times more likely to use mental health care services (P < .001 for all comparisons). CONCLUSIONS Identifying children in foster care using Medicaid eligibility files is prone to sampling bias that over-represents children in foster care who use more services.
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Affiliation(s)
- David M Rubin
- Pediatric Generalist Research Group, Safe Place: The Center for Child Protection and Health of the Division of General Pediatrics, Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
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