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Schechter SB, Bowles A, Ding L, Nkoy F, Tieder J, Lion KC, Meyer D, Kaiser SV. Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature. Pediatrics 2024; 153:e2022061176. [PMID: 38666310 DOI: 10.1542/peds.2022-061176] [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: 02/13/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes. METHODS Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction. RESULTS A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias. CONCLUSIONS Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.
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Affiliation(s)
| | - Adria Bowles
- University of California, San Francisco, San Francisco, California
| | - Lucky Ding
- University of California, San Francisco, San Francisco, California
| | - Flory Nkoy
- University of Utah, Salt Lake City, Utah
| | - Joel Tieder
- University of Washington, Seattle, Washington
| | | | - Dodi Meyer
- Columbia University Irving Medical Center, New York, New York
| | - Sunitha V Kaiser
- University of California, San Francisco, San Francisco, California
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Nkoy F, Stone B, Sheng X, Murphy N. High Parental Concern in Children With Medical Complexity: An Early Indicator of Illness. Hosp Pediatr 2023; 13:250-257. [PMID: 36720703 DOI: 10.1542/hpeds.2022-006876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES High concern about child's health is a common reason parents of children with medical complexity (CMC) seek care in emergency departments and hospitals. Factors driving parental concern are unknown. This study explores associations of parent's sociodemographic and child's clinical factors with high parental concern. PATIENT AND METHODS Secondary analysis of a pilot study of CMC and parents who used daily for 3 months MyChildCMC, a home monitoring app. Parents recorded their child's vital signs (temperature, heart rate, respiratory rate, oximetry), symptoms (pain, seizures, fluid intake/feeding, mental status), and oxygen use, and received immediate feedback. Parents rated their child's health concern on a 4-point Likert scale. Concern scores were dichotomized (3-4 = high, 1-2 = low) and modeled in a mixed-effects logistic regression to explore important associations. RESULTS We analyzed 1223 measurements from 24 CMC/parents, with 113 (9.24%) instances of high concern. Child factors associated with high parental concern were increased pain (odds ratio [OR], 5.10; 95% confidence interval [CI], 2.53-10.29; P < .01), increased oxygen requirement (OR, 28.91; 95% CI, 10.07-82.96; P < .01), reduced nutrition/fluid intake (OR, 71.58; 95% CI, 13.01-393.80; P < .01), and worsened mental status (OR, 2.15; 95% CI, 1.10-4.17, P = .02). No other associations existed. CONCLUSIONS Changes in CMC's clinical parameters were associated with high concern, which may be an early indicator of acute illness in CMC when it is the primary complaint. Monitoring and responding to high parental concerns may support CMC care at home.
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Affiliation(s)
- Flory Nkoy
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Bryan Stone
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Xiaoming Sheng
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
| | - Nancy Murphy
- University of Utah, Department of Pediatrics, Salt Lake City, Utah
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Schechter SB, Pantell MS, Parikh K, Nkoy F, McCulloh R, Fassl B, Kaiser SV. Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status. Acad Pediatr 2021; 21:1018-1024. [PMID: 33607330 DOI: 10.1016/j.acap.2021.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 08/18/2020] [Revised: 02/09/2021] [Accepted: 02/15/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities. METHODS Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA. RESULTS We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures. CONCLUSION At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.
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Affiliation(s)
- Sarah B Schechter
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser).
| | - Matthew S Pantell
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Center for Health and Community, University of California, San Francisco (MS Pantell)
| | - Kavita Parikh
- Department of Pediatrics, Children's National Medical Center (K Parikh), Washington, DC
| | - Flory Nkoy
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Russell McCulloh
- Department of Pediatrics, Children's Hospital & Medical Center (R McCulloh), Omaha, Nebr
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah (F Nkoy and B Fassl), Salt Lake City, Utah
| | - Sunitha V Kaiser
- Department of Pediatrics, University of California, San Francisco (SB Schechter, MS Pantell, and SV Kaiser); Philip R. Lee Institute for Health Policy Studies (MS Pantell and SV Kaiser), San Francisco, Calif; Department of Epidemiology and Biostatistics, University of California, San Francisco (SV Kaiser)
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Nkoy F, Stone B, Hofmann M, Fassl B, Zhu A, Mahtta N, Murphy N. Home-Monitoring Application for Children With Medical Complexity: A Feasibility Trial. Hosp Pediatr 2021; 11:492-502. [PMID: 33827786 DOI: 10.1542/hpeds.2020-002097] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Mobile apps are suggested for supporting home monitoring and reducing emergency department (ED) visits and hospitalizations for children with medical complexity (CMC). None have been implemented. We sought to assess the MyChildCMC app (1) feasibility for CMC home monitoring, (2) ability to detect early deteriorations before ED and hospital admissions, and (3) preliminary impact. METHODS Parents of CMC (aged 1-21 years) admitted to a children's hospital were randomly assigned to MyChildCMC or usual care. MyChildCMC subjects recorded their child's vital signs and symptoms daily for 3 months postdischarge and received real-time feedback. Feasibility measures included parent's enrollment, retention, and engagement. The preliminary impact was determined by using quality of life, parent satisfaction with care, and subsequent ED and hospital admissions and hospital days. RESULTS A total of 62 parents and CMC were invited to participate: 50 enrolled (80.6% enrollment rate) and were randomly assigned to MyChildCMC (n = 24) or usual care (n = 26). Retention at 1 and 3 months was 80% and 74%, and engagement was 68.3% and 62.6%. Run-chart shifts in vital signs were common findings preceding admissions. The satisfaction score was 26.9 in the MyChildCMC group and 24.1 in the control group (P = .035). No quality of life or subsequent admission differences occurred between groups. The 3-month hospital days (pre-post enrollment) decreased from 9.25 to 4.54 days (rate ratio = 0.49; 95% confidence interval = 0.39-0.62; P < .001) in the MyChildCMC group and increased from 1.08 to 2.46 days (rate ratio = 2.29; 95% confidence interval = 1.47-3.56; P < .001) in the control group. CONCLUSIONS MyChildCMC was feasible and appears effective, with the potential to detect early deteriorations in health for timely interventions that might avoid ED and hospitalizations. A larger and definitive study of MyChildCMC's impact and sustainability is needed.
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Affiliation(s)
- Flory Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bryan Stone
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Michelle Hofmann
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Angela Zhu
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Namita Mahtta
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nancy Murphy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
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Yeung Gregerson CH, Bakian AV, Wilkes J, Knighton AJ, Nkoy F, Sweney M, Filloux FM, Bonkowsky JL. Disparities in Pediatric Epilepsy Remission Are Associated With Race and Ethnicity. J Child Neurol 2019; 34:928-936. [PMID: 31502509 PMCID: PMC6842107 DOI: 10.1177/0883073819866623] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [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: 11/16/2022]
Abstract
OBJECTIVE The purpose of our study was to assess whether race/ethnicity was associated with seizure remission in pediatric epilepsy. METHODS This was a retrospective population-based cohort study of children who were evaluated for new-onset epilepsy in the clinic, emergency department, and/or hospital by a pediatric neurologist in an integrated health care delivery system. Children were between ages 6 months and 15 years at their initial presentation of epilepsy. The cohort, identified through an electronic database, was assembled over 6 years, with no less than 5 years of follow-up. All children were evaluated for race, ethnicity, insurance type, and socioeconomic background. Patient outcome was determined at the conclusion of the study period and categorized according to their epilepsy control as either drug resistant (pharmacoresistant and intractable) or drug responsive (controlled, probable remission, and terminal remission). RESULTS In the final cohort of 776 patients, 63% were drug responsive (control or seizure remission). After controlling for confounding socioeconomic and demographic factors, children of Hispanic ethnicity experienced reduced likelihood (hazard) of drug-responsive epilepsy (hazard ratio 0.6, P < .001), and had longer median time to remission (8 years; 95% CI 5.9-9.6 years) compared to white non-Hispanic patients (5.6 years; 95% CI 4.9-6.1 years). Among Hispanic patients, higher health care costs were associated with reduced likelihood of drug responsiveness. SIGNIFICANCE We found that Hispanic ethnicity is associated with a reduced likelihood of achieving seizure control and remission. This study suggests that factors associated with the race/ethnicity of patients contributes to their likelihood of achieving seizure freedom.
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Affiliation(s)
| | - Amanda V. Bakian
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Flory Nkoy
- Division of Inpatient Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Matthew Sweney
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah,Brain and Spine Center, Primary Children’s Hospital, Salt Lake City, Utah
| | - Francis M. Filloux
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Joshua L. Bonkowsky
- Division of Pediatric Neurology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah,Brain and Spine Center, Primary Children’s Hospital, Salt Lake City, Utah,Corresponding Author: Joshua L. Bonkowsky, Department of Pediatrics, University of Utah School of Medicine, 295 Chipeta Way/Williams Building, Salt Lake City, Utah 84108, , Phone: 801-581-6756, Fax: 801-581-4233
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Deering-Rice CE, Stockmann C, Romero EG, Lu Z, Shapiro D, Stone BL, Fassl B, Nkoy F, Uchida DA, Ward RM, Veranth JM, Reilly CA. Characterization of Transient Receptor Potential Vanilloid-1 (TRPV1) Variant Activation by Coal Fly Ash Particles and Associations with Altered Transient Receptor Potential Ankyrin-1 (TRPA1) Expression and Asthma. J Biol Chem 2016; 291:24866-24879. [PMID: 27758864 DOI: 10.1074/jbc.m116.746156] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 09/29/2016] [Indexed: 01/22/2023] Open
Abstract
Transient receptor potential (TRP) channels are activated by environmental particulate materials. We hypothesized that polymorphic variants of transient receptor potential vanilloid-1 (TRPV1) would be uniquely responsive to insoluble coal fly ash compared with the prototypical soluble agonist capsaicin. Furthermore, these changes would manifest as differences in lung cell responses to these agonists and perhaps correlate with changes in asthma symptom control. The TRPV1-I315M and -T469I variants were more responsive to capsaicin and coal fly ash. The I585V variant was less responsive to coal fly ash particles due to reduced translation of protein and an apparent role for Ile-585 in activation by particles. In HEK-293 cells, I585V had an inhibitory effect on wild-type TRPV1 expression, activation, and internalization/agonist-induced desensitization. In normal human bronchial epithelial cells, IL-8 secretion in response to coal fly ash treatment was reduced for cells heterozygous for TRPV1-I585V. Finally, both the I315M and I585V variants were associated with worse asthma symptom control with the effects of I315M manifesting in mild asthma and those of the I585V variant manifesting in severe, steroid-insensitive individuals. This effect may be due in part to increased transient receptor potential ankyrin-1 (TRPA1) expression by lung epithelial cells expressing the TRPV1-I585V variant. These findings suggest that specific molecular interactions control TRPV1 activation by particles, differential activation, and desensitization of TRPV1 by particles and/or other agonists, and cellular changes in the expression of TRPA1 as a result of I585V expression could contribute to variations in asthma symptom control.
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Affiliation(s)
- Cassandra E Deering-Rice
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Chris Stockmann
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Erin G Romero
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Zhenyu Lu
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Darien Shapiro
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Bryan L Stone
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah 84108
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah 84108
| | - Flory Nkoy
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah 84108
| | - Derek A Uchida
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah 84108
| | - Robert M Ward
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah 84108
| | - John M Veranth
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
| | - Christopher A Reilly
- From the Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah 84112 and
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Deering-Rice CE, Shapiro D, Romero EG, Stockmann C, Bevans TS, Phan QM, Stone BL, Fassl B, Nkoy F, Uchida DA, Ward RM, Veranth JM, Reilly CA. Activation of Transient Receptor Potential Ankyrin-1 by Insoluble Particulate Material and Association with Asthma. Am J Respir Cell Mol Biol 2016; 53:893-901. [PMID: 26039217 DOI: 10.1165/rcmb.2015-0086oc] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Inhaled irritants activate transient receptor potential ankyrin-1 (TRPA1), resulting in cough, bronchoconstriction, and inflammation/edema. TRPA1 is also implicated in the pathogenesis of asthma. Our hypothesis was that particulate materials activate TRPA1 via a mechanism distinct from chemical agonists and that, in a cohort of children with asthma living in a location prone to high levels of air pollution, expression of uniquely sensitive forms of TRPA1 may correlate with reduced asthma control. Variant forms of TRPA1 were constructed by mutating residues in known functional elements and corresponding to single-nucleotide polymorphisms in functional domains. TRPA1 activity was studied in transfected HEK-293 cells using allyl-isothiocynate, a model soluble electrophilic agonist; 3,5-ditert butylphenol, a soluble nonelectrophilic agonist and a component of diesel exhaust particles; and insoluble coal fly ash (CFA) particles. The N-terminal variants R3C and R58T exhibited greater, but not additive, activity with all three agonists. The ankyrin repeat domain-4 single nucleotide polymorphisms E179K and K186N exhibited decreased response to CFA. The predicted N-linked glycosylation site residues N747A and N753A exhibited decreased responses to CFA, which were not attributable to differences in cellular localization. The pore-loop residue R919Q was comparable to wild-type, whereas N954T was inactive to soluble agonists but not CFA. These data identify roles for ankyrin domain-4, cell surface N-linked glycans, and selected pore-loop domain residues in the activation of TRPA1 by insoluble particles. Furthermore, the R3C and R58T polymorphisms correlated with reduced asthma control for some children, which suggest that TRPA1 activity may modulate asthma, particularly among individuals living in locations prone to high levels of air pollution.
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Affiliation(s)
| | - Darien Shapiro
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
| | - Erin G Romero
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
| | - Chris Stockmann
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and.,2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Tatjana S Bevans
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
| | - Quang M Phan
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
| | - Bryan L Stone
- 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Bernhard Fassl
- 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Flory Nkoy
- 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Derek A Uchida
- 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Robert M Ward
- 2 Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - John M Veranth
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
| | - Christopher A Reilly
- 1 Department of Pharmacology and Toxicology, University of Utah, Salt Lake City, Utah; and
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Nkoy F, Fassl B, Stone B, Uchida DA, Johnson J, Reynolds C, Valentine K, Koopmeiners K, Kim EH, Savitz L, Maloney CG. Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals. Pediatrics 2015; 136:e1602-10. [PMID: 26527553 PMCID: PMC9923521 DOI: 10.1542/peds.2015-0285] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [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: 06/11/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals. METHODS Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses. RESULTS At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths. CONCLUSIONS Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals.
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Affiliation(s)
- Flory Nkoy
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Bryan Stone
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Derek A. Uchida
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | | | | | | | | | - Eun Hea Kim
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Lucy Savitz
- Intermountain Healthcare, Salt Lake City, Utah
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Stockmann C, Reilly CA, Fassl B, Gaedigk R, Nkoy F, Stone B, Roberts JK, Uchida DA, Leeder JS, Sherwin CMT, Spigarelli MG, Yost GS, Ward RM. Effect of CYP3A5*3 on asthma control among children treated with inhaled beclomethasone. J Allergy Clin Immunol 2015; 136:505-7. [PMID: 25825214 DOI: 10.1016/j.jaci.2015.02.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 02/10/2015] [Accepted: 02/10/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Chris Stockmann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Christopher A Reilly
- Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Roger Gaedigk
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Mo
| | - Flory Nkoy
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Bryan Stone
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jessica K Roberts
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Derek A Uchida
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - J Steven Leeder
- Division of Clinical Pharmacology, Toxicology and Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Mo
| | - Catherine M T Sherwin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael G Spigarelli
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Garold S Yost
- Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Robert M Ward
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah.
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Stockmann C, Ross JS, Sherwin CMT, Reilly CA, McDowell B, Fassl B, Nkoy F, Maloney CG, Spigarelli MG. Rate of asthma trial outcomes reporting on ClinicalTrials.gov and in the published literature. J Allergy Clin Immunol 2014; 134:1443-1446. [PMID: 25441299 DOI: 10.1016/j.jaci.2014.09.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2014] [Revised: 08/31/2014] [Accepted: 09/08/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Chris Stockmann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah.
| | - Joseph S Ross
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Conn
| | - Catherine M T Sherwin
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christopher A Reilly
- Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah
| | - Brittany McDowell
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Flory Nkoy
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Christopher G Maloney
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael G Spigarelli
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah; Department of Pharmacology/Toxicology, University of Utah College of Pharmacy, Salt Lake City, Utah
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Stockmann C, Fassl B, Gaedigk R, Nkoy F, Uchida DA, Monson S, Reilly CA, Leeder JS, Yost GS, Ward RM. Fluticasone propionate pharmacogenetics: CYP3A4*22 polymorphism and pediatric asthma control. J Pediatr 2013; 162:1222-7, 1227.e1-2. [PMID: 23290512 PMCID: PMC3620714 DOI: 10.1016/j.jpeds.2012.11.031] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [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: 06/11/2012] [Revised: 10/10/2012] [Accepted: 11/13/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine the relationship between allelic variations in genes involved in fluticasone propionate (FP) metabolism and asthma control among children with asthma managed with inhaled FP. STUDY DESIGN The relationship between variability in asthma control scores and genetic variation in drug metabolism was assessed by genotyping 9 single nucleotide polymorphisms in the CYP3A4, CYP3A5, and CYP3A7 genes. Genotype information was compared with asthma control scores (0=well controlled to 15=poorly controlled), determined using a questionnaire modified from the National Heart Lung and Blood Institute's Expert Panel 3 guidelines. RESULTS Our study cohort comprised 734 children with asthma (mean age, 8.8±4.3 years) and was predominantly male (61%) and non-Hispanic white (53%). More than one-half of the children (56%; n=413) were receiving an inhaled glucocorticoid daily, with FP the most frequently prescribed agent (65%). Among the children receiving daily FP, single nucleotide polymorphisms in CYP3A5 and CYP3A7 were not associated with asthma control scores. In contrast, asthma control scores were significantly improved in the 20 children (7%) with the CYP3A4*22 allele (median, 3; range, 0-6) compared with the 201 children without the CYP3A4*22 allele (median, 4; range, 0-15; P=.02). The presence of CYP3A4*22 was associated with improved asthma control scores by 2.1 points (95% CI, 0.5-3.8). CONCLUSION The presence of CYP3A4*22, which is associated with decreased hepatic CYP3A4 expression and activity, was accompanied by improved asthma control in the FP-treated children. Decreased CYP3A4 activity may improve asthma control with inhaled FP.
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Affiliation(s)
- Chris Stockmann
- Department of Pediatrics, University of Utah School of Medicine
,Department of Pharmacology/Toxicology, University of Utah College of Pharmacy
| | - Bernhard Fassl
- Department of Pediatrics, University of Utah School of Medicine
| | - Roger Gaedigk
- Developmental Pharmacology and Experimental Therapeutics Laboratory, University of Missouri Kansas City
| | - Flory Nkoy
- Department of Pediatrics, University of Utah School of Medicine
| | - Derek A. Uchida
- Department of Pediatrics, University of Utah School of Medicine
| | - Steven Monson
- Department of Pediatrics, University of Utah School of Medicine
| | | | - J. Steven Leeder
- Developmental Pharmacology and Experimental Therapeutics Laboratory, University of Missouri Kansas City
| | - Garold S. Yost
- Department of Pharmacology/Toxicology, University of Utah College of Pharmacy
| | - Robert M. Ward
- Department of Pediatrics, University of Utah School of Medicine
,Department of Pharmacology/Toxicology, University of Utah College of Pharmacy
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Hammond E, Fetzer J, Belnap T, Rowley B, Hall C, Nkoy F. Impact of Recording of Pre-Analytical Specimen Handling Conditions for ER and PR Testing in Women with Breast Cancer. Cancer Res 2009. [DOI: 10.1158/0008-5472.sabcs-09-4154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Background: Hormone receptor testing is important in the management of women with breast cancer. We previously reported potential adverse effects of variable specimen and prolonged specimen handling conditions on ER (estrogen receptor) test results (2005 SABCS, abstract#5107).Objective: To compare prevalence of ER and PR (progesterone receptor) negative test results following standardization of pre-analytical specimen handling conditions at Intermountain facilities.Methods: Prospective, quasi-experimental study design of 6 Intermountain facilities. Facilities were separated into 2 categories: experimental (2 facilities) and control (4 facilities) groups. Pre-analytical specimen handling conditions (including recording of time to fixative and duration of fixation in neutral buffered formalin) were standardized at experimental facilities but not at control facilities. Standardization consisted of educating operating and grossing room staff about appropriate specimen handling and the value of recording time to fixation and fixative duration as a way to improve pre-analytic standardization. OR staff was called in any cases where times were not recorded. Study population includes women undergoing breast cancer surgery and who were tested for ER/PR status between January 2008 and January 2009. Specimen handling conditions and ER/PR test results were collected manually. Covariates were retrieved from cancer registry and included age, grade, positive lymph nodes, specimen type, and tumor stage. Multivariate logistic regression was used to compare prevalence of ER and PR negativity between experimental and control facilities after controlling for covariates.Results: 1054 women with breast cancer were tested for ER/PR status during the study period. The average age was 60.2 years (59.2 years for control cases and 61.1 years for the experimental group). The overall prevalence of ER and PR negative tests was respectively 18.5% and 27.3%. Average time to fixative at experimental facilities was 18.4 minutes (SE=3.1; 95% CI, 12.2-25.6) and average time in fixative was 18.0 hours (SE=0.4; 95% CI, 17.2-18.8). Compared to experimental facilities, both the prevalence of ER and PR negativity was higher (16.9% vs 19.7%) and (23.9% vs 30.0%) at control facilities. After controlling for covariates there was no difference in prevalence of ER negativity (p=0.13) between the two groups. However, the prevalence of PR negativity remains significantly higher (p<0.01) at control facilities compared to experimental facilities even after controlling for covariates.Conclusions: The prevalence of ER and PR negative results was lower following staff education and recording of pre-analytical specimen handling conditions. Our data suggest that staff education and recording of pre-analytical specimen handling conditions has the potential to optimize hormone receptor test results. It also shows the feasibility of fixing tissue routinely after less than an hour interval between time of breast cancer tissue removal and fixation and underscores the value of standardization of pre-analytic handling as a method to improve ER and PR testing on breast cancer specimens.
Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4154.
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Affiliation(s)
| | | | | | | | - C. Hall
- 1Intermountain Healthcare, UT,
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Srivastava R, Downey EC, Feola P, Samore M, Coburn L, Holubkov R, Mundorff M, Nkoy F, Desrochers D, James BC, Rosenbaum P, Young PC, Dean JM, O'Gorman M. Quality of life of children with neurological impairment who receive a fundoplication for gastroesophageal reflux disease. J Hosp Med 2007; 2:165-73. [PMID: 17549766 DOI: 10.1002/jhm.167] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [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: 11/07/2022]
Abstract
BACKGROUND Children with neurological impairment (NI) commonly have gastroesophageal reflux disease (GERD) treated with a fundoplication. The impact of this procedure on quality of life is poorly understood. OBJECTIVES To examine the quality of life of children with NI who have received a fundoplication for GERD and of their caregivers. METHODS The study was a prospective cohort study of children with NI and GERD who underwent a fundoplication at a children's hospital between January 1, 2005, and July 7, 2006. Quality of life of the children was assessed with the Child Health Questionnaire (CHQ) and of the caregivers with the Short-Form Health Survey Status (SF-36) and Parenting Stress Index (PSI), both at baseline and 1 month after fundoplication. Functional status was assessed using the WeeFIM. Repeated-measures analyses were performed. RESULTS Forty-four of the 63 parents (70%) were enrolled. The median WeeFIM score was 31.2 versus the age-normal score of 83 (P = .001). Compared with the baseline scores, mean CHQ scores improved over 1 month in the domains of bodily pain (32.8 vs. 47.5, P = .01), role limitations-physical (30.6 vs. 56.6, P = .01), mental health (62.7 vs. 70.6, P = .01), family limitation of activities (43.3 vs. 55.1, P = .03), and parental time (43.0 vs. 55.3, P = .03). The parental SF-36 domain of vitality improved from baseline over 1 month (41.3 vs. 48.2, P = .001), but there were no changes from baseline in Parenting Stress scores. CONCLUSIONS Parents reported that the quality of life of children with NI who receive a fundoplication for GERD was improved from baseline in several domains 1 month after surgery. The quality of life and stress of caregivers did not improve in nearly all domains, at least in the short term.
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Affiliation(s)
- Rajendu Srivastava
- University of Utah Health Sciences Center, Salt Lake City, Utah 84113, USA.
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Sause WT, Nkoy F, Rees W, Brammer A, Pinto K. Improved cancer outcomes across multiple institutions using an integrated data system. J Clin Oncol 2004. [DOI: 10.1200/jco.2004.22.90140.6030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- W. T. Sause
- Intermountain Health Care, Salt LakeCity, UT
| | - F. Nkoy
- Intermountain Health Care, Salt LakeCity, UT
| | - W. Rees
- Intermountain Health Care, Salt LakeCity, UT
| | - A. Brammer
- Intermountain Health Care, Salt LakeCity, UT
| | - K. Pinto
- Intermountain Health Care, Salt LakeCity, UT
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