Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma: Development, Implementation, and Lessons Learned.

2016

534-42

2016

1869-0327

<p><strong>INTRODUCTION: </strong>For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial.</p>

<p><strong>METHODS: </strong>Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic(®) EHR. All sites implementing EHR-based CDS built the rules by using the vendor's CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations.</p>

<p><strong>RESULTS: </strong>The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed.</p>

<p><strong>CONCLUSIONS: </strong>The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.</p>

10.4338/ACI-2015-10-CR-0144

Appl Clin Inform

27437059

Shared decision making and behavioral impairment: a national study among children with special health care needs.

2012

153

2012 Sep

1471-2431

<p><strong>BACKGROUND: </strong>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).</p>

<p><strong>METHOD: </strong>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.</p>

<p><strong>RESULTS: </strong>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.</p>

<p><strong>CONCLUSION: </strong>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.</p>

10.1186/1471-2431-12-153

BMC Pediatr

22998626

A qualitative assessment of reasons for nonurgent visits to the emergency department: parent and health professional opinions.

2012

220-5

2012 Mar

1535-1815

<p><strong>OBJECTIVE: </strong>Each day, children incur more than 69,000 emergency department (ED) visits, with 58% to 82% of them for nonurgent reasons. The objectives of this study were to elicit and to describe guardians' and health professionals' opinions on reasons for nonurgent pediatric ED visits.</p>

<p><strong>METHODS: </strong>Focus groups sessions were held with 3 groups of guardians, 2 groups of primary care practitioners, and 1 group of pediatric emergency medicine physicians. Participants identified unique factors and their importance related to nonurgent ED use.</p>

<p><strong>RESULTS: </strong>A total of 25 guardians and 42 health professionals participated. Guardians had at least 1 child younger than 5 years, most were self-identified racial/ethnic minorities, and nearly all had taken a child to an ED. Guardians focused on perceived illness severity in their children and needs for diagnostic testing or other interventions, as well as accessibility and availability at times of day that worked for them. Professionals focused on systems issues concerning availability of appointments, as well as parents' lack of knowledge of medical conditions and sense of when use of the ED was appropriate.</p>

<p><strong>CONCLUSIONS: </strong>Guardians' concerns about perceptions of severity of illness in children and their schedules must be considered to effectively reduce nonurgent ED use, which may differ from the perceptions of professionals. Health professionals and systems seeking ways to decrease ED utilization may be able to better match capacity to demand both by increasing accessibility to primary care and by working to overcome guardians' perceptions that only EDs can handle acute illnesses or injuries.</p>

10.1097/PEC.0b013e318248b431

Pediatr Emerg Care

22344210

Shared decision-making and health care expenditures among children with special health care needs.

2012

99-107

2012 Jan

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>To understand the association between shared decision-making (SDM) and health care expenditures and use among children with special health care needs (CSHCN).</p>

<p><strong>METHODS: </strong>We identified CSHCN &lt;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.</p>

<p><strong>RESULTS: </strong>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.</p>

<p><strong>CONCLUSIONS: </strong>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.</p>

10.1542/peds.2011-1352

Pediatrics

22184653

Effects of an education and training intervention on caregiver knowledge of nonurgent pediatric complaints and on child health services utilization.

2013

331-6

2013 Mar

1535-1815

<p><strong>OBJECTIVES: </strong>The objective of this study was to test the impact of an education and training intervention about management of common childhood illnesses on caregiver knowledge and health service use by an index child.</p>

<p><strong>METHODS: </strong>This was a quasi-experimental, preintervention-postintervention pilot study of a primary care-based intervention among 32 caregivers of urban children aged 7 months to 5 years. Intervention consisted of a 90-minute educational activity developed after input from focus groups and taught by pediatric nurses; it addressed management of fever, colds, and minor trauma in children at home. Caregiver knowledge before, immediately after, and 6 months after intervention was tested using a written instrument. Health services utilization for an index child in the family was collected 6 months before and after intervention.</p>

<p><strong>RESULTS: </strong>Caregiver knowledge, as assessed by mean score on the test instrument, increased immediately after the intervention. It was lower at 6-month follow-up but remained higher than pretest. Total health services utilization, adjusted for patient and caregiver factors, did not change significantly 6 months after the intervention. After-hours calls to the primary care physician increased from a mean of 0.33 to 1.46 per patient (P = 0.047), making it the only behavior with significant change. Preintervention health services utilization was the strongest positive predictor of postintervention health services use.</p>

<p><strong>CONCLUSIONS: </strong>The primary care-based intervention led to increased caregiver knowledge regarding management of common minor childhood illnesses and to increased after-hours telephone use. There was no significant decrease in ED use. To reduce reliance on the ED for nonurgent conditions, additional strategies may be needed.</p>

10.1097/PEC.0b013e31828512c7

Pediatr Emerg Care

23426249

Shared decision-making in pediatrics: a national perspective.

2010

306-14

2010 Aug

1098-4275

<p><strong>OBJECTIVES: </strong>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.</p>

<p><strong>PATIENTS AND METHODS: </strong>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.</p>

<p><strong>RESULTS: </strong>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.</p>

<p><strong>CONCLUSIONS: </strong>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.</p>

10.1542/peds.2010-0526

Pediatrics

20624804

Impact of electronic health record-based alerts on influenza vaccination for children with asthma.

2009

159-69

2009 Jul

1098-4275

<p><strong>OBJECTIVE: </strong>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.</p>

<p><strong>METHODS: </strong>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 &gt;80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices.</p>

<p><strong>RESULTS: </strong>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 (&gt;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.</p>

<p><strong>CONCLUSIONS: </strong>Clinical alerts were associated with only modest improvements in influenza vaccination rates.</p>

10.1542/peds.2008-2823

Pediatrics

19564296

Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population.

2007

707-14

10/2007

1098-4275

<p><strong>OBJECTIVES: </strong>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.</p>

<p><strong>METHODS: </strong>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.</p>

<p><strong>RESULTS: </strong>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.</p>

<p><strong>CONCLUSIONS: </strong>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.</p>

10.1542/peds.2007-0257

Pediatrics

17908756

Improving adherence to otitis media guidelines with clinical decision support and physician feedback.

2013

e1071-81

2013 Apr

1098-4275

<p><strong>OBJECTIVE: </strong>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).</p>

<p><strong>METHODS: </strong>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.</p>

<p><strong>RESULTS: </strong>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.</p>

<p><strong>CONCLUSIONS: </strong>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.</p>

10.1542/peds.2012-1988

Pediatrics

23478860

Adoption of electronic medical record-based decision support for otitis media in children.

2015

489-513

04/2015

1475-6773

<p><strong>OBJECTIVE: </strong>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.</p>

<p><strong>STUDY SETTING: </strong>A total of 41,391 OM visits with 108 clinicians at 16 pediatric practices between February 2009 and August 2010.</p>

<p><strong>STUDY DESIGN: </strong>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.</p>

<p><strong>DATA COLLECTION: </strong>Extraction from a common EHR.</p>

<p><strong>PRINCIPAL FINDINGS: </strong>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.</p>

<p><strong>CONCLUSIONS: </strong>Performance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.</p>

10.1111/1475-6773.12240

Health Serv Res

25287670