Patient Characteristics Associated with Differences in Admission Frequency for Diabetic Ketoacidosis in United States Children's Hospitals.

2016

104-10

2016 Apr

1097-6833

OBJECTIVES: To determine across and within hospital differences in the predictors of 365-day admission frequency for diabetic ketoacidosis (DKA) in children at US children's hospitals.

STUDY DESIGN: Multicenter retrospective cohort analysis of 12 449 children 2-18 years of age with a diagnosis of DKA in 42 US children's hospitals between 2004 and 2012. The main outcome of interest was the maximum number of DKA admissions experienced by each child within any 365-day interval during a 5-year follow-up period. The association between patient characteristics and the maximum number of DKA admissions within a 365-day interval was examined across and within hospitals.

RESULTS: In the sample, 28.3% of patients admitted for DKA experienced at least 1 additional DKA admission within the following 365 days. Across hospitals, patient characteristics associated with increasing DKA admission frequency were public insurance (OR 1.97, 95% CI 1.71-2.26), non-Hispanic black race (OR 2.40, 95% CI 2.02-2.85), age ≥12 (OR 1.98, 95% CI 1.7-2.32), female sex (OR 1.41, 95% CI 1.29-1.55), and mental health comorbidity (OR 1.36, 95% CI 1.13-1.62). Within hospitals, non-Hispanic black race was associated with higher odds of 365-day admission in 59% of hospitals, and public insurance was associated with higher odds in 56% of hospitals. Older age, female sex, and mental health comorbidity were associated with higher odds of 365-day admission in 42%, 29%, and 15% of hospitals, respectively.

CONCLUSIONS: Across children's hospitals, certain patient characteristics are associated with more frequent DKA admissions. However, these factors are not associated with increased DKA admission frequency for all hospitals.

10.1016/j.jpeds.2015.12.015

J. Pediatr.

26787380

Fidelity evaluation of the dialogue around respiratory illness treatment (DART) program communication training.

2022

2022 Mar 14

1873-5134

<p><strong>OBJECTIVE: </strong>To evaluate receipt fidelity of communication training content included in a multifaceted intervention known to reduce antibiotic over-prescribing for pediatric acute respiratory tract infections (ARTIs), by examining the degree to which clinicians implemented the intended communication behavior changes.</p>

<p><strong>METHODS: </strong>Parents were surveyed regarding clinician communication behaviors immediately after attending 1026 visits by children 6 months to &lt;&nbsp;11 years old diagnosed with ARTIs by 53 clinicians in 18 pediatric practices. Communication outcomes analyzed were whether clinicians: (A) provided both a combined (negative + positive) treatment recommendation and a contingency plan (full implementation); (B) provided either a combined treatment recommendation or a contingency plan (partial implementation); or (C) provided neither (no implementation). We used mixed effects multinomial logistic regression to determine whether these 3 communication outcomes changed between baseline and the time periods following each of 3 training modules.</p>

<p><strong>RESULTS: </strong>After completing the communication training, the adjusted probability of clinicians fully implementing the intended communication behavior changes increased by an absolute 8.1% compared to baseline (95% Confidence Interval [CI]: 2.4%, 13.8%, p&nbsp;=&nbsp;.005).</p>

<p><strong>CONCLUSIONS: </strong>Our findings support the receipt fidelity of the intervention's communication training content.</p>

<p><strong>PRACTICAL IMPLICATIONS: </strong>Clinicians can be trained to implement communication behaviors that may aid in reducing antibiotic over-prescribing for ARTIs.</p>

10.1016/j.pec.2022.03.011

Patient Educ Couns

35341612

Variation in Dexamethasone Dosing and Use Outcomes for Inpatient Croup.

2021

2021 Dec 01

2154-1671

<p><strong>OBJECTIVES: </strong>Evaluate the association between dexamethasone dosing and outcomes for children hospitalized with croup.</p>

<p><strong>METHODS: </strong>This study was nested within a multisite prospective cohort study of children aged 6 months to 6 years admitted to 1 of 5 US children's hospitals between July 2014 and June /2016. Multivariable linear and logistic mixed-effects regression models were used to examine the association between the number of dexamethasone doses (1 vs &gt;1) and outcomes (length of stay [LOS], cost, and 30-day same-cause reuse). All multivariable analyses included a site-specific random effect to account for clustering within hospital and were adjusted for age, sex, race and ethnicity, presenting severity, medical complexity, insurance, caregiver education, and hospital. In cost analyses, we controlled for LOS.</p>

<p><strong>RESULTS: </strong>Among 234 children hospitalized with croup, patient characteristics did not differ by number of doses. The proportion receiving &gt;1 dose varied by hospital (range 27.9%-57.1%). In adjusted analyses, &gt;1 dose was not associated with same-cause reuse (odds ratio 0.87 [95% confidence interval (CI): 0.26 to 2.95]) but was associated with 45% longer LOS (relative risk = 1.45 [95% CI: 1.30 to 1.62]). When we controlled for LOS, &gt;1 dose was not associated with differential cost ($-31.2 [95% CI $-424.4 to $362.0]). Eighty-two (35%) children received dexamethasone before presentation.</p>

<p><strong>CONCLUSIONS: </strong>We found significant interhospital variation in dexamethasone dosing and LOS. When we controlled for severity on presentation, &gt;1 dexamethasone dose was associated with longer LOS but not reuse. Although incomplete adjustment for severity is one possible explanation, some providers may routinely keep children hospitalized to administer multiple dexamethasone doses.</p>

10.1542/hpeds.2021-005854

Hosp Pediatr

34846064

Associations Between Quality Measures and Outcomes for Children Hospitalized With Bronchiolitis.

2020

2020 Oct 26

2154-1671

<p><strong>OBJECTIVES: </strong>To use adherence to the Pediatric Respiratory Illness Measurement System (PRIMES) indicators to evaluate the strength of associations for individual indicators with length of stay (LOS) and cost for bronchiolitis.</p>

<p><strong>METHODS: </strong>We prospectively enrolled children with bronchiolitis at 5 children's hospitals between July 1, 2014, and June 30, 2016. We examined associations between adherence to each individual PRIMES indicator for bronchiolitis and LOS and cost. Sixteen indicators were included, 9 "overuse" indicators for care that should not occur and 7 "underuse" indicators for care that should occur. We performed mixed effects linear regression to examine the association between adherence to each individual indicator and LOS (hours) and cost (dollars). All models controlled for patient demographics, patient complexity, and hospital.</p>

<p><strong>RESULTS: </strong>We enrolled 699 participants. The mean age was 8 months; 56% were male, 38% were white, and 63% had public insurance. Three indicators were significantly associated with shorter LOS and lower cost. All 3 indicators were overuse indicators and related to laboratory testing: no blood cultures (adjusted mean difference in LOS: -24.3 hours; adjusted mean cost difference: -$731, &lt; .001), no complete blood cell counts (LOS: -17.8 hours; cost: -$399, &lt; .05), and no respiratory syncytial virus testing (LOS: -16.6 hours; cost: -$272, &lt; .05). Two underuse indicators were associated with higher cost: documentation of oral intake at discharge ($671, &lt; .01) and documentation of hospital follow-up ($538, &lt; .05).</p>

<p><strong>CONCLUSIONS: </strong>A subset of PRIMES quality indicators for bronchiolitis are strongly associated with improved outcomes and can serve as important measures for future quality improvement efforts.</p>

10.1542/hpeds.2020-0175

Hosp Pediatr

33106253

Reducing Antibiotic Prescribing in Primary Care for Respiratory Illness.

2020

2020 Aug 03

1098-4275

<p><strong>BACKGROUND: </strong>One-third of outpatient antibiotic prescriptions for pediatric acute respiratory tract infections (ARTIs) are inappropriate. We evaluated a distance learning program's effectiveness for reducing outpatient antibiotic prescribing for ARTI visits.</p>

<p><strong>METHODS: </strong>In this stepped-wedge clinical trial run from November 2015 to June 2018, we randomly assigned 19 pediatric practices belonging to the Pediatric Research in Office Settings Network or the NorthShore University HealthSystem to 4 wedges. Visits for acute otitis media, bronchitis, pharyngitis, sinusitis, and upper respiratory infection for children 6 months to &lt;11 years old without recent antibiotic use were included. Clinicians received the intervention as 3 program modules containing online tutorials and webinars on evidence-based communication strategies and antibiotic prescribing, booster video vignettes, and individualized antibiotic prescribing feedback reports over 11 months. The primary outcome was overall antibiotic prescribing rates for all ARTI visits. Mixed-effects logistic regression compared prescribing rates during each program module and a postintervention period to a baseline control period. Odds ratios were converted to adjusted rate ratios (aRRs) for interpretability.</p>

<p><strong>RESULTS: </strong>Among 72 723 ARTI visits by 29 762 patients, intention-to-treat analyses revealed a 7% decrease in the probability of antibiotic prescribing for ARTI overall between the baseline and postintervention periods (aRR 0.93; 95% confidence interval [CI], 0.90-0.96). Second-line antibiotic prescribing decreased for streptococcal pharyngitis (aRR 0.66; 95% CI, 0.50-0.87) and sinusitis (aRR 0.59; 95% CI, 0.44-0.77) but not for acute otitis media (aRR 0.93; 95% CI, 0.83-1.03). Any antibiotic prescribing decreased for viral ARTIs (aRR 0.60; 95% CI, 0.51-0.70).</p>

<p><strong>CONCLUSIONS: </strong>This program reduced antibiotic prescribing during outpatient ARTI visits; broader dissemination may be beneficial.</p>

10.1542/peds.2020-0038

Pediatrics

32747473

Social Disadvantage, Access to Care, and Disparities in Physical Functioning Among Children Hospitalized with Respiratory Illness.

2020

e1-e8

2020 Feb 11

1553-5606

<p><strong>BACKGROUND AND OBJECTIVES: </strong>Understanding disparities in child health-related quality of life (HRQoL) may reveal opportunities for targeted improvement. This study examined associations between social disadvantage, access to care, and child physical functioning before and after hospitalization for acute respiratory illness.</p>

<p><strong>METHODS: </strong>From July 1, 2014, to June 30, 2016, children ages 8-16 years and/or caregivers of children 2 weeks to 16 years admitted to five tertiary care children's hospitals for three common respiratory illnesses completed a survey on admission and within 2 to 8 weeks after discharge. Survey items assessed social disadvantage (minority race/ ethnicity, limited English proficiency, low education, and low income), difficulty/delays accessing care, and baseline and follow-up HRQoL physical functioning using the Pediatric Quality of Life Inventory (PedsQL, range 0-100). We examined associations between these three variables at baseline and follow-up using multivariable, mixed-effects linear regression models with multiple imputation sensitivity analyses for missing data.</p>

<p><strong>RESULTS: </strong>A total of 1,325 patients and/or their caregivers completed both PedsQL assessments. Adjusted mean baseline PedsQL scores were significantly lower for patients with social disadvantage markers, compared with those of patients with none (78.7 for &gt;3 markers versus 85.5 for no markers, difference -6.1 points (95% CI: -8.7, -3.5). The number of social disadvantage markers was not associated with mean follow-up PedsQL scores. Difficulty/delays accessing care were associated with lower PedsQL scores at both time points, but it was not a significant effect modifier between social disadvantage and PedsQL scores.</p>

<p><strong>CONCLUSIONS: </strong>Having social disadvantage markers or difficulty/delays accessing care was associated with lower baseline physical functioning; however, differences were reduced after hospital discharge.</p>

10.12788/jhm.3359

J Hosp Med

32118564

Vaccination Status and Adherence to Quality Measures for Acute Respiratory Tract Illnesses.

2020

2020 Feb 10

2154-1671

<p><strong>OBJECTIVES: </strong>To assess the relationship between vaccination status and clinician adherence to quality measures for children with acute respiratory tract illnesses.</p>

<p><strong>METHODS: </strong>We conducted a multicenter prospective cohort study of children aged 0 to 16 years who presented with 1 of 4 acute respiratory tract illness diagnoses (community-acquired pneumonia, croup, asthma, and bronchiolitis) between July 2014 and June 2016. The predictor variable was provider-documented up-to-date (UTD) vaccination status. Our primary outcome was clinician adherence to quality measures by using the validated Pediatric Respiratory Illness Measurement System (PRIMES). Across all conditions, we examined overall PRIMES composite scores and overuse (including indicators for care that should not be provided, eg, C-reactive protein testing in community-acquired pneumonia) and underuse (including indicators for care that should be provided, eg, dexamethasone in croup) composite subscores. We examined differences in length of stay, costs, and readmissions by vaccination status using adjusted linear and logistic regression models.</p>

<p><strong>RESULTS: </strong>Of the 2302 participants included in the analysis, 92% were documented as UTD. The adjusted mean difference in overall PRIMES scores by UTD status was not significant (adjusted mean difference -0.3; 95% confidence interval: -1.9 to 1.3), whereas the adjusted mean difference was significant for both overuse (-4.6; 95% confidence interval: -7.5 to -1.6) and underuse (2.8; 95% confidence interval: 0.9 to 4.8) composite subscores. There were no significant adjusted differences in mean length of stay, cost, and readmissions by vaccination status.</p>

<p><strong>CONCLUSIONS: </strong>We identified lower adherence to overuse quality indicators and higher adherence to underuse quality indicators for children not UTD, which suggests that clinicians "do more" for hospitalized children who are not UTD.</p>

10.1542/hpeds.2019-0245

Hosp Pediatr

32041781

Pediatric Respiratory Illness Measurement System (PRIMES) Scores and Outcomes.

2019

2019 Jul 26

1098-4275

<p><strong>BACKGROUND AND OBJECTIVES: </strong>The Pediatric Respiratory Illness Measurement System (PRIMES) generates condition-specific composite quality scores for asthma, bronchiolitis, croup, and pneumonia in hospital-based settings. We sought to determine if higher PRIMES composite scores are associated with improved health-related quality of life, decreased length of stay (LOS), and decreased reuse.</p>

<p><strong>METHODS: </strong>We conducted a prospective cohort study of 2334 children in 5 children's hospitals between July 2014 and June 2016. Surveys administered on admission and 2 to 6 weeks postdischarge assessed the Pediatric Quality of Life Inventory (PedsQL). Using medical records data, 3 PRIMES scores were calculated (0-100 scale; higher scores = improved adherence) for each condition: an overall composite (including all quality indicators for the condition), an overuse composite (including only indicators for care that should not be provided [eg, chest radiographs for bronchiolitis]), and an underuse composite (including only indicators for care that should be provided [eg, dexamethasone for croup]). Multivariable models assessed relationships between PRIMES composite scores and (1) PedsQL improvement, (2) LOS, and (3) 30-day reuse.</p>

<p><strong>RESULTS: </strong>For every 10-point increase in PRIMES overuse composite scores, LOS decreased by 8.8 hours (95% confidence interval [CI] -11.6 to -6.1) for bronchiolitis, 3.1 hours (95% CI -5.5 to -1.0) for asthma, and 2.0 hours (95% CI -3.9 to -0.1) for croup. Bronchiolitis overall composite scores were also associated with shorter LOS. PRIMES composites were not associated with PedsQL improvement or reuse.</p>

<p><strong>CONCLUSIONS: </strong>Better performance on some PRIMES condition-specific composite measures is associated with decreased LOS, with scores on overuse quality indicators being a primary driver of this relationship.</p>

10.1542/peds.2019-0242

Pediatrics

31350359

Home Smoke Exposure and Health-Related Quality of Life in Children with Acute Respiratory Illness.

2019

212-217

2019 Apr

1553-5606

<p><strong>OBJECTIVE: </strong>This study aims to assess whether secondhand smoke (SHS) exposure has an impact on health-related quality of life (HRQOL) in children with acute respiratory illness (ARI).</p>

<p><strong>METHODS: </strong>This study was nested within a multicenter, prospective cohort study of children (two weeks to 16 years) with ARI (emergency department visits for croup and hospitalizations for croup, asthma, bronchiolitis, and pneumonia) between July 1, 2014 and June 30, 2016. Subjects were surveyed upon enrollment for sociodemographics, healthcare utilization, home SHS exposure (0 or ≥1 smoker in the home), and child HRQOL (Pediatric Quality of Life Physical Functioning Scale) for both baseline health (preceding illness) and acute illness (on admission). Data on insurance status and medical complexity were collected from the Pediatric Hospital Information System database. Multivariable linear mixed regression models examined associations between SHS exposure and HRQOL.</p>

<p><strong>RESULTS: </strong>Home SHS exposure was reported in 728 (32%) of the 2,309 included children. Compared with nonexposed children, SHS-exposed children had significantly lower HRQOL scores for baseline health (mean difference -3.04 [95% CI -4.34, -1.74]) and acute illness (-2.16 [-4.22, -0.10]). Associations were strongest among children living with two or more smokers. HRQOL scores were lower among SHS-exposed children for all four conditions but only significant at baseline for bronchiolitis (-2.94 [-5.0, -0.89]) and pneumonia (-4.13 [-6.82, -1.44]) and on admission for croup (-5.71 [-10.67, -0.75]).</p>

<p><strong>CONCLUSIONS: </strong>Our study demonstrates an association between regular SHS exposure and decreased HRQOL with a dose-dependent response for children with ARI, providing further evidence of the negative impact of SHS.</p>

10.12788/jhm.3164

J Hosp Med

30933671

Perceived Access to Outpatient Care and Hospital Reutilization following Acute Respiratory Illnesses.

2018

2018 Jul 24

1876-2867

<p><strong>OBJECTIVE: </strong>Efforts to decrease hospital revisits often focus on improving access to outpatient follow-up. Our objective was to assess the relationship between perceived access to timely office-based care and subsequent 30-day revisits following hospital discharge for four common respiratory illnesses.</p>

<p><strong>METHODS: </strong>This was a prospective cohort study of children 2 weeks-16 years admitted to five United States children's hospitals for asthma, bronchiolitis, croup, or pneumonia between 7/2014-6/2016. Hospital and ED (in the case of croup) admission surveys administered to caregivers included the Consumer Assessments of Healthcare Providers and Systems (CAHPS©) Timely Access to Care. Access composite scores (range 0-100, higher score indicating better access) were linked with 30-day ED revisits and inpatient readmissions from the Pediatric Health Information System (PHIS). The relationship between access to timely care and repeat utilization was assessed using multivariable logistic regression adjusting for demographics, hospitalization, and home/outpatient factors.</p>

<p><strong>RESULTS: </strong>Of the 2,438 children enrolled, 2179 (89%) reported an office visit in the last 6 months. Average access composite score was 52.0 (standard deviation 36.3). In adjusted analyses, higher access scores were associated with higher odds of 30-day ED revisits (odds ratio [OR] 1.07; 95% confidence interval [CI] 1.02-1.13) - particularly for croup (OR 1.17; 95% CI 1.02-1.36) - but not inpatient readmissions (OR 1.02; 95% CI 0.96 - 1.09).</p>

<p><strong>CONCLUSIONS: </strong>Perceived access to timely office-based care was associated with significantly higher odds of subsequent ED revisit. Focusing solely on enhancing timely access to care following discharge for common respiratory illnesses may be insufficient to prevent repeat utilization.</p>

10.1016/j.acap.2018.07.001

Acad Pediatr

30053631