1
|
Stephan AM, Platt S, Levine DA, Qiu Y, Buchhalter L, Lyons TW, Gaines N, Cruz AT, Sudanagunta S, Hardee IJ, Eisenberg JR, Tamas V, McAneney C, Chinta SS, Yeung C, Root JM, Fant C, Dunnick J, Pifko E, Campbell C, Bruce M, Srivastava G, Pruitt CM, Hueschen LA, Ugalde IT, Becker C, Granda E, Klein EJ, Kaplan RL. A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children. Pediatrics 2024; 153:e2023063153. [PMID: 38239108 DOI: 10.1542/peds.2023-063153] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Accepted: 11/02/2023] [Indexed: 02/02/2024] Open
Abstract
OBJECTIVES To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children. METHODS We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis. RESULTS We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00). CONCLUSIONS We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.
Collapse
Affiliation(s)
| | - Shari Platt
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine
| | - Deborah A Levine
- Division of Pediatric Emergency Medicine, Departments of Emergency Medicine
| | - Yuqing Qiu
- Population Health Sciences, NewYork-Presbyterian/Weill Cornell Medicine, New York, New York
| | - Lillian Buchhalter
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Nakia Gaines
- Division of Pediatric Emergency Medicine, University of Texas Southwestern, Children's Medical Center Dallas, Dallas, Texas
| | - Andrea T Cruz
- Divisions of Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Sindhu Sudanagunta
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Isabel J Hardee
- Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, Colorado
| | - Jonathan R Eisenberg
- Division of Pediatric Emergency Medicine, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Vanessa Tamas
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of California San Diego, Rady Children's Hospital San Diego, San Diego, California
| | - Constance McAneney
- Department of Pediatrics, Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sri S Chinta
- Department of Pediatrics, Division of Emergency Medicine, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Claudia Yeung
- Department of Emergency Medicine, Phoenix Children's Hospital, Phoenix, Arizona
| | - Jeremy M Root
- Division of Emergency Medicine, Children's National Hospital, Washington, District of Columbia
| | - Colleen Fant
- Department of Pediatrics, Division of Emergency Medicine, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Jennifer Dunnick
- Division of Pediatric Emergency Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Elysha Pifko
- Division of Emergency Medicine, Nemours Children's Hospital of Delaware, Wilmington, Delaware
| | - Christine Campbell
- Division of Pediatric Emergency Medicine, Children's of Alabama, University of Alabama at Birmingham, Birmingham, Alabama
| | - Madison Bruce
- University of Alabama at Birmingham, Heersink School of Medicine, Birmingham, Alabama
| | | | - Christopher M Pruitt
- Department of Pediatrics, Division of Emergency Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Leslie A Hueschen
- Division of Pediatric Emergency Medicine, Children Mercy Hospital, University of Missouri-Kansas City, Kansas City, Missouri
| | - Irma T Ugalde
- Division of Emergency Medicine, McGovern, Utah Health, Houston, Texas
| | - Callie Becker
- Division of Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, Minnesota
| | - Elena Granda
- Department of Pediatrics, Rio Hortega University Hospital, Valladolid, Spain
| | - Eileen J Klein
- Division of Emergency Medicine, University Department of Pediatrics, Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Ron L Kaplan
- Division of Emergency Medicine, University Department of Pediatrics, Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| |
Collapse
|
2
|
Abstract
OBJECTIVES Concussion is a commonly encountered diagnosis for pediatric emergency medicine (PEM) providers, yet little is known regarding referral patterns to specialists. Our goal was to assess PEM providers' referral patterns and current usage of standardized evaluation tools. METHODS This study was conducted as cross-sectional survey of PEM providers recruited from the American Academy of Pediatrics Section on Emergency Medicine Listserv. Surveys were distributed at 3 time points between December 1, 2020, and February 28, 2021, and included multiple choice, Likert scale, and free text questions. Descriptive statistics and bivariate analyses were used to describe the sample and compare responses between those with variable experience and confidence in concussion management. RESULTS In total, 162 of 491 Listserv members (33.0%) completed the survey. The factors most often reported to assist in referral decisions were history of severe (92.6%) or multiple (90.7%) prior concussions, prolonged symptom duration (89.5%), and severity of current symptoms (84.6%). Most providers reported having large experience (63.0%) and confidence (54.9%) in managing concussion. Standardized symptom scales (8.0%), vestibular (11.7%) and balance assessments (13.0%), and prognostic tools (6.8%) were infrequently used. Most (64.2%) providers felt specialty referral was important. More than 80% reported high likelihood to use an accurate risk stratification tool to facilitate referral. CONCLUSIONS Although most PEM providers reported significant experience and confidence in managing pediatric concussion, standardized assessment tools were infrequently used. Most were likely to use a risk stratification tool to assist in specialty referral. Future studies should assess the ability of targeted referral strategies to improve recovery for concussed youth.
Collapse
Affiliation(s)
- Daniel J Corwin
- From the Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Jeremy M Root
- Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC
| | - Mark R Zonfrillo
- Departments of Emergency Medicine and Pediatrics, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, RI
| | - Danny G Thomas
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| |
Collapse
|
3
|
Root JM, Fong J, Badolato G, Madati PJ. Rest-Based Concussion Management of Pediatric Emergency Medicine Providers. Pediatr Emerg Care 2021; 37:e631-e635. [PMID: 30672900 DOI: 10.1097/pec.0000000000001727] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/26/2022]
Abstract
OBJECTIVES This study aimed to survey pediatric emergency medicine (PEM) providers on their management of 2 hypothetical acute concussion scenarios. We hypothesized that most providers would recommend a management strategy based on cognitive and physical rest. METHODS Fifty-nine percent (46/78) of PEM providers that were surveyed completed the study. The survey consisted of 2 clinical scenarios-a female patient with a mild concussion and a male patient with a moderate concussion. Practitioners were asked questions regarding how they would hypothetically manage these patients in terms of recommendations for returning to school and returning to sports. RESULTS Eighty-six percent of providers recommended moderate time off from school for the moderate concussion scenario compared with 67% of providers in the mild concussion scenario (P = 0.008). In regard to return to sports, all providers recommended moderate time off in both scenarios, including 78% of providers who recommended clearance by a physician in the moderate concussion scenario. CONCLUSIONS In both of our hypothetical concussion scenarios, including a very mild head injury, most PEM providers surveyed recommended a management strategy that included a moderate degree of a delay of return to school and sports. Given recent evidence suggesting that prolonged rest does not reduce the risk of prolonged concussion symptoms, recommendations of periods of cognitive rest, particularly absences from school, should be approached cautiously. Future studies should examine why providers are recommending rest-based treatment strategies and the potential benefits of active rehabilitation.
Collapse
Affiliation(s)
- Jeremy M Root
- From the Children's National Medical Center, Washington, DC
| | - Jeanette Fong
- Loma Linda University Children's Hospital, Loma Linda, CA
| | - Gia Badolato
- From the Children's National Medical Center, Washington, DC
| | | |
Collapse
|
4
|
Root JM, Gai J, Sady MD, Vaughan CG, Madati PJ. Identifying Risks for Persistent Postconcussive Symptoms in a Pediatric Emergency Department: An Examination of a Clinical Risk Score. Arch Clin Neuropsychol 2021; 37:30-39. [PMID: 33993203 DOI: 10.1093/arclin/acab032] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/13/2021] [Accepted: 04/20/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE External examination of a clinical risk score to predict persistent postconcussive symptoms (PPCS) in a pediatric emergency department (ED). METHODS Prospective cohort study of 5- to 18-year-old patients diagnosed with an acute concussion. Risk factors were collected at diagnosis and participants (n = 85) were followed to determine PPCS 30 days postinjury. Univariate logistic regression analyses were completed to examine associations of risk factors with PPCS. RESULTS Headache and total clinical risk score were associated with increased odds of PPCS in the univariate analyses, OR 3.37 (95% CI 1.02, 11.10) and OR 1.25 (95% CI 1.02, 1.52), respectively. Additionally, teenage age group, history of prolonged concussions, and risk group trended toward association with PPCS, OR 4.79 (95% CI 0.93, 24.7), OR 3.41 (95% CI 0.88, 13.20), and OR 2.23 (95% CI 0.88, 5.66), respectively. CONCLUSION Our study supports the use of multiple variables of a clinical risk score to assist with ED risk stratification for pediatric patients at risk for PPCS.
Collapse
Affiliation(s)
- J M Root
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| | - J Gai
- Children's Research Institute, Children's National Health System, Washington, DC, USA
| | - M D Sady
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC, USA
| | - C G Vaughan
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC, USA
| | - P J Madati
- Division of Emergency Medicine, Children's National Health System, Washington, DC, USA
| |
Collapse
|
5
|
Root JM, Sady MD, Gai J, Vaughan CG, Madati PJ. Effect of Cognitive and Physical Rest on Persistent Postconcussive Symptoms following a Pediatric Head Injury. J Pediatr 2020; 227:184-190.e4. [PMID: 32702425 DOI: 10.1016/j.jpeds.2020.07.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [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: 05/18/2020] [Revised: 07/10/2020] [Accepted: 07/15/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To evaluate the effect of cognitive and physical rest on persistent postconcussive symptoms in a pediatric population. STUDY DESIGN A prospective cohort study of 5- to 18-year-olds diagnosed with an acute concussion in a tertiary care pediatric emergency department was conducted from December 2016 to May 2019. Participants (n = 119) were followed over 1 month to track days off from school and sports and the development of persistent postconcussive symptoms (residual concussion symptoms beyond 1 month). Participants were dichotomized into minimal (≤2) and moderate (>2) rest, based on days off from school and sports after a concussion. Univariate and multivariable logistic regression analyses were completed to examine associations with persistent postconcussive symptoms. RESULTS Of the participants in our study, 24% had persistent postconcussive symptoms. Adolescent age, history of prolonged concussion recovery, and headache at presentation were associated with higher odds of persistent postconcussive symptoms in univariate analyses. In a multivariable logistic regression model, only adolescent age was associated with increased odds of persistent postconcussive symptoms. Compared with the minimal cognitive rest group, moderate cognitive rest did not decrease the odds of persistent postconcussive symptoms (aOR, 1.15; 95% CI, 0.44-2.99). Compared with the minimal physical rest group, moderate physical rest also did not decrease the odds of persistent postconcussive symptoms (aOR, 3.17; 95% CI, 0.35-28.78). CONCLUSIONS Emerging evidence supports early return to light activity for recovery of acute pediatric concussion. Our study adds to this management approach as we did not find that rest from school and sports resulted in a decreased odds of persistent postconcussive symptoms.
Collapse
Affiliation(s)
- Jeremy M Root
- Division of Emergency Medicine, Children's National Health System, Washington, DC.
| | - Maegan D Sady
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC
| | - Jiaxiang Gai
- Biostatistics and Study Methodology Division, Clinical and Translational Science Institute at Children's National (CTSI-CN), Washington, DC
| | - Christopher G Vaughan
- Division of Pediatric Neuropsychology, Children's National Health System, Washington, DC
| | - Ponda J Madati
- Division of Emergency Medicine, Children's National Health System, Washington, DC
| |
Collapse
|
6
|
Abstract
Emerging evidence supports an active approach for acute pediatric concussion management. The current practices of pediatric emergency providers following acute concussions has not been well studied. We prospectively enrolled 134 pediatric patients with an acute concussion. Providers completed a real-time survey to assess their recommendations for time off from school and sports. Seven to 10 days post-injury, patient compliance with provider recommendations was assessed. Forty-seven (35.1%) providers recommended moderate time off from school. In this cohort (n = 44), 14 (31.8%) patients took more than 2 days off from school. When minimal rest was prescribed (n = 80), 26 (32.5%) patients took more than 2 days off from school, P = .94. One third of our pediatric emergency providers are still recommending moderate time off from school. Regardless of physician prescriptions, patients took a similar amount of time off from school. Our study questions the influence of physician recommendations on management of acute pediatric concussions.
Collapse
Affiliation(s)
- Jeremy M Root
- 1 Children's National Health System, Washington, DC, USA
| | - Brittany McNamara
- 1 Children's National Health System, Washington, DC, USA.,2 GW Medical Faculty Associates, Washington, DC, USA
| | - Matt Ledda
- 1 Children's National Health System, Washington, DC, USA.,3 Johns Hopkins University, Washington, DC, USA
| | - Ponda J Madati
- 1 Children's National Health System, Washington, DC, USA
| |
Collapse
|
7
|
Root JM, Zuckerbraun NS, Wang L, Winger D, Brent D, Kontos A, Hickey R. History of Somatization Is Associated with Prolonged Recovery from Concussion. J Pediatr 2016; 174:39-44.e1. [PMID: 27059916 PMCID: PMC4925238 DOI: 10.1016/j.jpeds.2016.03.020] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [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: 01/23/2016] [Revised: 02/22/2016] [Accepted: 03/04/2016] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To determine the association between a history of somatization and prolonged concussion symptoms, including sex differences in recovery. STUDY DESIGN A prospective cohort study of 10- to 18-year-olds with an acute concussion was conducted from July 2014 to April 2015 at a tertiary care pediatric emergency department. One hundred twenty subjects completed the validated Children's Somatization Inventory (CSI) for pre-injury somatization assessment and Postconcussion Symptoms Scale (PCSS) at diagnosis. PCSS was re-assessed by phone at 2 and 4 weeks. CSI was assessed in quartiles with a generalized estimating equation model to determine relationship of CSI to PCSS over time. RESULTS The median age of our study participants was 13.8 years (IQR 11.5, 15.8), 60% male, with separate analyses for each sex. Our model showed a positive interaction between total CSI score, PCSS and time from concussion for females P < .01, and a statistical trend for males, P = .058. Females in the highest quartile of somatization had higher PCSS than the other 3 CSI quartiles at each time point (B -26.7 to -41.1, P values <.015). CONCLUSIONS Patients with higher pre-injury somatization had higher concussion symptom scores over time. Females in the highest somatization quartile had prolonged concussion recovery with persistently high symptom scores at 4 weeks. Somatization may contribute to sex differences in recovery, and assessment at the time of concussion may help guide management and target therapy.
Collapse
Affiliation(s)
- Jeremy M Root
- Emergency Medicine and Trauma Services, Children's National Medical Center, Washington, DC.
| | - Noel S. Zuckerbraun
- Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Li Wang
- Office of Clinical Research, Heath Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Dan Winger
- Office of Clinical Research, Heath Sciences, University of Pittsburgh, Pittsburgh, PA
| | - David Brent
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anthony Kontos
- Department of Orthopaedic Surgery, University of Pittsburgh, Pittsburgh, PA
| | - Robert Hickey
- Division of Pediatric Emergency Medicine, Children’s Hospital of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
8
|
Sopher AB, Gerken AT, Blaner WS, Root JM, McMahon DJ, Oberfield SE. Metabolic manifestations of polycystic ovary syndrome in nonobese adolescents: retinol-binding protein 4 and ectopic fat deposition. Fertil Steril 2012; 97:1009-15. [PMID: 22341881 DOI: 10.1016/j.fertnstert.2012.01.111] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2011] [Revised: 01/10/2012] [Accepted: 01/18/2012] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To determine whether nonobese adolescents with polycystic ovary syndrome (PCOS) have higher levels of retinol-binding protein 4 (RBP4) and ectopic fat than controls and whether RBP4 and ectopic fat correlate with comorbidities of metabolic disease. DESIGN Cross-sectional case-control study. SETTING Pediatric clinical research center based in a quaternary care medical center. PATIENT(S) Twenty-four nonobese adolescents between the ages of 13 and 21 years, 13 with PCOS and 11 controls. INTERVENTION(S) Measurement of RBP4, insulin resistance, lipids, and body composition. MAIN OUTCOME MEASURE(S) Retinol-binding protein 4, reproductive and adrenal hormones, insulin resistance, intrahepatic and intramyocellular lipid levels, and visceral adipose tissue. RESULT(S) Adolescents with PCOS had higher intrahepatic lipid content and a statistical trend for higher RBP4 compared with controls. Retinol-binding protein 4 correlated with body fat, triglycerides, insulin resistance, and androgens but not intrahepatic lipid content; however, when adjusted for body fat, the correlation between RBP4 and triglycerides weakened to a statistical trend and was no longer statistically significant for the other measures. CONCLUSION(S) This small preliminary study of nonobese adolescent girls suggests that RBP4 may be involved in the dyslipidemia associated with PCOS and that there may be an independent relationship between RBP4 and triglycerides but not between RBP4 and insulin resistance. Although intrahepatic lipid content was higher in PCOS, it did not correlate with RBP4, triglycerides, or insulin resistance.
Collapse
Affiliation(s)
- Aviva B Sopher
- Department of Pediatrics, Columbia University Medical Center, New York, New York 10032, USA.
| | | | | | | | | | | |
Collapse
|
9
|
Steiner JW, Root JM, Michel RL. The transformation of hospital laboratories: why regionalization, consolidation, and reengineering will lead laboratories into the 21st century. Hosp Technol Ser 1995; 14:1-33. [PMID: 10153679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
In 1990 we predicted that the growth of prospective payment and fixed reimbursement plans would force hospitals to transform the hospital laboratory into a cost center. The need to create alternative modes of care would further lead hospitals to create regional laboratory consortia. This would include the "commercialization" of the laboratory so that it could become a regional resource and expand outreach activities. This report updates events since 1990. Indeed, the arrival of prospective payment and fixed reimbursement has caused a radical upheaval among health care providers in every part of the country. The transformation was more rapid than we expected, particularly in two areas. First, the commercial laboratory industry devoured itself. By 1995 the consolidation movement ended and three huge national laboratory chains now provide laboratory services throughout the United States. Second, not only did prospective payment arrive in the form of capitated contracts for laboratory services, but it arrived with remarkable speed. It was coupled with the absolute decline for three years in Medicare reimbursement for lab services. Such changes to reimbursement levels have seriously undercut the financial viability of the laboratory industry. Hospital-based laboratories are responding to these pressures with three strategies: reengineering, consolidation, and networking. Six identifiable trends will drive the transformation of laboratories into regional provider consortia between now and the year 2000. We predict that the speed of this transformation will be even faster than that experienced by the consolidation of commercial laboratories. This will occur because hospital labs are already a component within integrated delivery systems. As these systems transform and evolve, the laboratories must transform in concert. Our experience indicates that laboratory consolidation delivers economic benefits that are considerably greater than either networking or reengineering. Consolidation, accompanied by new testing technologies and tighter data links, will lead the transformation of today's hospital laboratory into a "virtual" laboratory. Such laboratories will be self-sufficient, capable of performing all but esoteric tests in-house. It will be a "laboratory without walls," emphasizing testing performed at the point of care, be it bedside, physician's office, clinic, nursing home, ambulance, workplace, or patients' homes. A combination of economic and organizational pressures will cause hospital-based laboratories to adopt some form of regionalization within the next two to three years.
Collapse
Affiliation(s)
- J W Steiner
- Chi Laboratory Systems, Inc. (CLS), Ann Arbor, MI, USA
| | | | | |
Collapse
|
10
|
Steiner JW, Root JM, Buck E. Regionalization, Part 3. Lab networks: models of regional cooperation. MLO Med Lab Obs 1994; 26:38-40, 41-2. [PMID: 10137183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
11
|
Steiner JW, Root JM, Buck E. Lab regionalization: structural options for the age of managed competition. Part 2. MLO Med Lab Obs 1994; 26:48-51. [PMID: 10171914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
12
|
Steiner JW, Root JM, Buck E. The regionalization of laboratory services. Part 1. MLO Med Lab Obs 1994; 26:22-9. [PMID: 10171880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
13
|
Steiner JW, Root JM. Service and value: the decommoditization of laboratory services and the impact of managed care. Clin Lab Manage Rev 1994; 8:296, 291-5. [PMID: 10134744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
|
14
|
Steiner JW, Root JM, White DC. Laboratory cost and utilization containment. Clin Lab Manage Rev 1991; 5:372-4, 376, 378-84. [PMID: 10113716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The authors analyzed laboratory costs and utilization in 3,771 cases of Medicare inpatients admitted to a New England academic medical center ("the Hospital") from October 1, 1989 to September 30, 1990. The data were derived from the Hospital's Decision Resource System comprehensive data base. The authors established a historical reference point for laboratory costs as a percentage of total inpatient costs using 1981-82 Medicare claims data and cost report information. Inpatient laboratory costs were estimated at 9.5% of total inpatient costs for pre-Diagnostic Related Groups (DRGs) Medicare discharges. Using this reference point and adjusting for the Hospital's 1990 case mix, the "expected" laboratory cost was 9.3% of total cost. In fact, the cost averaged 11.5% (i.e., 24% above the expected cost level), and costs represented an even greater percentage of DRG reimbursement at 12.9%. If we regard the reimbursement as a total cost target (to eliminate losses from Medicare), then that 12.9% is 39% above the "expected" laboratory proportion of 9.3%. The Hospital lost an average of $1,091 on each DRG inpatient. The laboratory contributed 29% to this loss per case. Compared to other large hospitals, the Hospital was slightly (3%) above the mean direct cost per on-site test and significantly (58%) above the mean number of inpatient tests per inpatient day compared to large teaching hospitals. The findings suggest that careful laboratory cost analyses will become increasingly important as the proportion of patients reimbursed in a fixed manner grows. The future may hold a prospective zero-based laboratory budgeting process based on predictable patterns of DRG admissions or other fixed-reimbursement admission and laboratory utilization patterns.
Collapse
|
15
|
Steiner JW, Root JM. Regionalization of laboratory care: a viable option for the 21st century. Hosp Technol Ser 1990; 9:1-24. [PMID: 10110924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The conversion of the hospital laboratory to a cost center under pressure of prospective payment and fixed reimbursement is increasingly forcing hospitals to consider alternative modes for delivery of laboratory care. Changes in the health care environment, amended statutes and regulations, and, particularly, dramatic developments in laboratory equipment, methodologies, and data processing technology make it advisable and feasible to contemplate the creation of regional laboratory consortia. A fundamental step in this direction is the "commercialization" of the hospital laboratory through a change in focus from being an in-house support program to becoming a regional resource. By the same token, the hospital laboratory can become an effective competitor of independent laboratories and be reconverted to a profit center. Creation of hospital laboratory consortia in a splintered, competitive environment requires a committed entrepreneurial effort and convincing evidence of potential benefits. The sequence of steps needed to achieve regional laboratory integration include concerting the goals and objectives of the interested parties, creating an appropriate committee structure, conducting a feasibility assessment, identifying alternative organizational and operational options, selecting a favorite option viewed by all parties as a win/win proposition, developing a business plan, and determining an implementation action plan. The major disadvantages of regionalization of laboratories are employee displacement, potential leveling of quality standards, and reduced hospital control. The major advantages include elimination of duplicate capital, personnel, and service costs, improved efficiency through test batching, reduced unit costs, increased technical capability through staff, instrument, and systems sharing, disengagement from hospital-imposed limitations, strengthened ability to penetrate the marketplace, freeing of hospital space for more direct patient care activities, and achieving a means for bonding physicians to the institutions.
Collapse
|
16
|
Thomassen MJ, Demko CA, Doershuk CF, Root JM. Pseudomonas aeruginosa isolates: comparisons of isolates from campers and from sibling pairs with cystic fibrosis. Pediatr Pulmonol 1985; 1:40-5. [PMID: 3932947 DOI: 10.1002/ppul.1950010110] [Citation(s) in RCA: 31] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Sputum or deep throat specimen cultures were obtained from 47 cystic fibrosis (CF) patients residing together at an eight-day summer camp. Pre-camp, initial day, final day and post-camp cultures were obtained and Pseudomonas aeruginosa isolates were characterized by morphology, serotype, pigment production, serum sensitivity, antibiotic susceptibility patterns, hemolysis on blood agar, and CO2 growth requirement. Of the 47 patients, four were not chronically colonized with Pseudomonas and did not become colonized at camp. Analysis of the isolates from the other 43 revealed no significant alteration in the Pseudomonas colonization pattern. Cultures obtained from four sibling pairs among the campers and from 20 additional pairs of siblings revealed that siblings in 20/24 pairs had at least one identical serotype in common. Of the criteria used for characterization, serotyping was the most definitive method for strain identification. Serotyping by both the Homma system and the International system did not detect any serotype at a frequency of more than 31%. In this study, the predominant P. aeruginosa strain of the colonized patients did not change, and non-colonized individuals did not become colonized with P. aeruginosa.
Collapse
|
17
|
Root JM. Six strategies for providing hospital laboratory services. Pathologist 1984; 38:807-9. [PMID: 10269207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
|