Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age.

2015

358-65

06/2015

1553-5606

BACKGROUND: Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs.

OBJECTIVE: Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants.

DESIGN: Retrospective cross-sectional study in 2013.

SETTING: Thirty-three hospitals in the Pediatric Health Information System.

PATIENTS: Infants aged ≤56 days with a diagnosis of fever.

EXPOSURES: The presence and content of ED-based febrile infant CPGs assessed by electronic survey.

MEASUREMENTS: Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs.

RESULTS: We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs.

CONCLUSIONS: CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs.

10.1002/jhm.2329

J Hosp Med

25684689

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

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

Comparison of Empiric Antibiotics for Acute Osteomyelitis in Children.

2018

280-287

2018 Apr

2154-1663

<p><strong>OBJECTIVES: </strong>Broad-spectrum antibiotics are commonly used for the empiric treatment of acute hematogenous osteomyelitis and often target methicillin-resistant(MRSA) with medication-associated risk and unknown treatment benefit. We aimed to compare clinical outcomes among patients with osteomyelitis who did and did not receive initial antibiotics used to target MRSA.</p>

<p><strong>METHODS: </strong>A retrospective cohort study of 974 hospitalized children 2 to 18 years old using the Pediatric Health Information System database, augmented with clinical data. Rates of hospital readmission, repeat MRI and 72-hour improvement in inflammatory markers were compared between treatment groups.</p>

<p><strong>RESULTS: </strong>Repeat MRI within 7 and 180 days was more frequent among patients who received initial MRSA coverage versus methicillin-sensitive(MSSA)-only coverage (8.6% vs 4.1% within 7 days [= .02] and 12% vs 5.8% within 180 days [&lt; .01], respectively). Ninety- and 180-day hospital readmission rates were similar between coverage groups (9.0% vs 8.7% [= .87] and 10.9% vs 11.2% [= .92], respectively). Patients with MRSA- and MSSA-only coverage had similar rates of 72-hour improvement in C-reactive protein values, but patients with MRSA coverage had a lower rate of 72-hour white blood cell count normalization compared with patients with MSSA-only coverage (4.2% vs 16.4%;= .02).</p>

<p><strong>CONCLUSIONS: </strong>In this study of children hospitalized with acute hematogenous osteomyelitis, early antibiotic treatment used to target MRSA was associated with a higher rate of repeat MRI compared with early antibiotic treatment used to target MSSA but not MRSA. Hospital readmission rates were similar for both treatment groups.</p>

10.1542/hpeds.2017-0079

Hosp Pediatr

29626010

Application of the Rochester Criteria to Identify Febrile Infants With Bacteremia and Meningitis.

2019

22-27

2019 Jan

1535-1815

<p><strong>OBJECTIVES: </strong>The Rochester criteria were developed to identify febrile infants aged 60 days or younger at low-risk of bacterial infection and do not include cerebrospinal fluid (CSF) testing. Prior studies have not specifically assessed criteria performance for bacteremia and bacterial meningitis (invasive bacterial infection). Our objective was to determine the sensitivity of the Rochester criteria for detection of invasive bacterial infection.</p>

<p><strong>METHODS: </strong>Retrospective cohort study of febrile infants aged 60 days or younger with invasive bacterial infections evaluated at 8 pediatric emergency departments from July 1, 2012, to June 30, 2014. Potential cases were identified from the Pediatric Health Information System using International Classification of Diseases, Ninth Revision diagnosis codes for bacteremia, meningitis, urinary tract infection, and fever. Medical record review was then performed to confirm presence of an invasive bacterial infection and to evaluate the Rochester criteria: medical history, symptoms or ill appearance, results of urinalysis, complete blood count, CSF testing (if obtained), and blood, urine, and CSF culture. An invasive bacterial infection was defined as growth of pathogenic bacteria from blood or CSF culture.</p>

<p><strong>RESULTS: </strong>Among 82 febrile infants aged 60 days or younger with invasive bacterial infection, the sensitivity of the Rochester criteria were 92.7% (95% confidence interval [CI], 84.9%-96.6%) overall, 91.7% (95% CI, 80.5%-96.7%) for neonates 28 days or younger, and 94.1% (95% CI, 80.9%-98.4%) for infants aged 29 to 60 days old. Six infants with bacteremia, including 1 neonate with bacterial meningitis, met low-risk criteria.</p>

<p><strong>CONCLUSIONS: </strong>The Rochester criteria identified 92% of infants aged 60 days or younger with invasive bacterial infection. However, 1 neonate 28 days or younger with meningitis was classified as low-risk.</p>

10.1097/PEC.0000000000001421

Pediatr Emerg Care

29406479

Empiric Antibiotic Use and Susceptibility in Infants With Bacterial Infections: A Multicenter Retrospective Cohort Study.

2017

2017 Jul 20

2154-1663

<p><strong>OBJECTIVES: </strong>To assess hospital differences in empirical antibiotic use, bacterial epidemiology, and antimicrobial susceptibility for common antibiotic regimens among young infants with urinary tract infection (UTI), bacteremia, or bacterial meningitis.</p>

<p><strong>METHODS: </strong>We reviewed medical records from infants &lt;90 days old presenting to 8 US children's hospitals with UTI, bacteremia, or meningitis. We used the Pediatric Health Information System database to identify cases and empirical antibiotic use and medical record review to determine infection, pathogen, and antimicrobial susceptibility patterns. We compared hospital-level differences in antimicrobial use, pathogen, infection site, and antimicrobial susceptibility.</p>

<p><strong>RESULTS: </strong>We identified 470 infants with bacterial infections: 362 (77%) with UTI alone and 108 (23%) with meningitis or bacteremia. Infection type did not differ across hospitals (P = .85). Empirical antibiotic use varied across hospitals (P &lt; .01), although antimicrobial susceptibility patterns for common empirical regimens were similar. A third-generation cephalosporin would have empirically treated 90% of all ages, 89% in 7- to 28-day-olds, and 91% in 29- to 89-day-olds. The addition of ampicillin would have improved coverage in only 4 cases of bacteremia and meningitis. Ampicillin plus gentamicin would have treated 95%, 89%, and 97% in these age groups, respectively.</p>

<p><strong>CONCLUSIONS: </strong>Empirical antibiotic use differed across regionally diverse US children's hospitals in infants &lt;90 days old with UTI, bacteremia, or meningitis. Antimicrobial susceptibility to common antibiotic regimens was similar across hospitals, and adding ampicillin to a third-generation cephalosporin minimally improves coverage. Our findings support incorporating empirical antibiotic recommendations into national guidelines for infants with suspected bacterial infection.</p>

10.1542/hpeds.2016-0162

Hosp Pediatr

28729240

Admission chest radiographs predict illness severity for children hospitalized with pneumonia.

2014

559-64

2014 Sep

1553-5606

<p><strong>OBJECTIVE: </strong>To assess whether radiographic findings predict outcomes among children hospitalized with pneumonia.</p>

<p><strong>METHODS: </strong>This retrospective study included children &lt;18 years of age from 4 children's hospitals admitted in 2010 with clinical and radiographic evidence of pneumonia. Admission radiographs were categorized as single lobar, unilateral or bilateral multilobar, or interstitial. Pleural effusions were classified as absent, small, or moderate/large. Propensity scoring was used to adjust for potential confounders, including need for supplemental oxygen, intensive care, and mechanical ventilation, as well as hospital length of stay and duration of supplemental oxygen.</p>

<p><strong>RESULTS: </strong>There were 406 children (median age, 3 years). Infiltrate patterns included: single lobar, 61%; multilobar unilateral, 13%; multilobar bilateral, 16%; and interstitial, 10%. Pleural effusion was present in 21%. Overall, 63% required supplemental oxygen (median duration, 31.5 hours), 8% required intensive care, and 3% required mechanical ventilation. Median length of stay was 51.5 hours. Compared with single lobar infiltrate, all other infiltrate patterns were associated with need for intensive care; only bilateral multilobar infiltrate was associated with need for mechanical ventilation (adjusted odds ratio [aOR]: 3.0, 95% confidence interval [CI]: 1.2-7.9). Presence of effusion was associated with increased length of stay and duration of supplemental oxygen; only moderate/large effusion was associated with need for intensive care (aOR: 3.2, 95% CI: 1.1-8.9) and mechanical ventilation (aOR: 14.8, 95% CI: 9.8-22.4).</p>

<p><strong>CONCLUSIONS: </strong>Admission radiographic findings are associated with important hospital outcomes and care processes and may help predict disease severity.</p>

10.1002/jhm.2227

J Hosp Med

24942619

Dexamethasone and risk of bleeding in children undergoing tonsillectomy.

2014

872-9

2014 May

1097-6817

<p><strong>OBJECTIVE: </strong>To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding.</p>

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using a multihospital administrative database.</p>

<p><strong>SETTING: </strong>Thirty-six US children's hospitals.</p>

<p><strong>SUBJECTS: </strong>Children undergoing same-day tonsillectomy between the years 2004 and 2010.</p>

<p><strong>METHODS: </strong>We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7.</p>

<p><strong>CONCLUSIONS: </strong>In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.</p>

10.1177/0194599814521555

Otolaryngol Head Neck Surg

24493786

Variation in quality of tonsillectomy perioperative care and revisit rates in children's hospitals.

2014

280-8

2014 Feb

1098-4275

<p><strong>OBJECTIVE: </strong>To describe the quality of care for routine tonsillectomy at US children's hospitals.</p>

<p><strong>METHODS: </strong>We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital.</p>

<p><strong>RESULTS: </strong>Of 139,715 children who underwent same-day tonsillectomy, 10,868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P &lt; .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%).</p>

<p><strong>CONCLUSIONS: </strong>Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.</p>

10.1542/peds.2013-1884

Pediatrics

24446446