First name
Lisa
Middle name
M
Last name
McLeod

Title

Measuring overuse of continuous pulse oximetry in bronchiolitis and developing strategies for large-scale deimplementation: study protocol for a feasibility trial.

Year of Publication

2019

Number of Pages

68

Date Published

2019

ISSN Number

2055-5784

Abstract

<p><strong>Background: </strong>Deimplementation, the systematic elimination of low-value practices, has emerged as an important focus within implementation science. Bronchiolitis is the leading cause of infant hospitalization. Among stable inpatients with bronchiolitis who do not require supplemental oxygen, continuous pulse oximetry monitoring is recognized as an overused, low-value practice in pediatric hospital medicine. There is strong scientific evidence and practice guideline support for limiting pulse oximetry monitoring of stable children with bronchiolitis who do not require supplemental oxygen, yet the practice remains common. This study aims to (1) characterize the extent of this overuse in hospitals located in the USA and Canada, (2) identify barriers and facilitators of successful deimplementation of continuous pulse oximetry monitoring in bronchiolitis, and (3) develop consensus strategies for large-scale deimplementation. In addition to identifying feasible strategies for deimplementation, this study will test the feasibility of data collection approaches to be employed in a large-scale deimplementation trial.</p>

<p><strong>Methods: </strong>This multicenter study will be performed in approximately 38 hospitals in the Pediatric Research in Inpatient Settings Network. In Aim 1, we will determine the rate of overuse within each hospital by performing repeated cross-sectional observational sampling of continuous pulse oximetry monitoring of stable bronchiolitis patients age 8 weeks through 23 months who do not require supplemental oxygen. In Aim 2, we will use the Consolidated Framework for Implementation Research (CFIR) as a framework for semi-structured interviews with key stakeholders (physician, nurse, respiratory therapist, administrator, and parent) at the highest- and lowest-overuse hospitals to understand barriers and facilitators of continuous pulse oximetry monitoring deimplementation. In Aim 3, we will use a theory-based causal model to match the identified barriers and facilitators to potential strategies for deimplementation. Candidate strategies will be discussed with a panel of stakeholders from hospitals with high rates of overuse to assess feasibility and acceptability. A questionnaire ranking strategies based on feasibility, acceptability, and impact will be administered to a broader group of stakeholders to arrive at consensus about promising strategies for large-scale deimplementation to be tested in a subsequent trial.</p>

<p><strong>Discussion: </strong>Effective strategies for deimplementing continuous pulse oximetry monitoring of stable patients with bronchiolitis have not been well characterized. The findings of this study will provide further understanding of factors that facilitate deimplementation in pediatric hospital settings and provide pilot and feasibility data to inform a trial of large-scale deimplementation of this overused practice.</p>

<p><strong>Trial registration: </strong>Not applicable. This study does not meet the World Health Organization definition of a clinical trial.</p>

DOI

10.1186/s40814-019-0453-2

Alternate Title

Pilot Feasibility Stud

PMID

31123593

Title

Treatment of Osteonecrosis in Children and Adolescents With Acute Lymphoblastic Leukemia.

Year of Publication

2016

Number of Pages

223-229.e2

Date Published

2016 Apr

ISSN Number

2152-2669

Abstract

<p><strong>BACKGROUND: </strong>Cure rates for acute lymphoblastic leukemia (ALL) have improved, but as therapy has intensified, the burden of osteonecrosis (ON) has increased. Limited data exist regarding surgical interventions for pediatric ALL patients with ON.</p>

<p><strong>MATERIALS AND METHODS: </strong>A multi-center cohort of children with newly diagnosed ALL was established with Pediatric Health Information System (PHIS) data from 43 freestanding children's hospitals from 1999 to 2011. Patients with ON identified by International Classification of Diseases, Ninth Revision (ICD-9) code were followed for up to 5 years after index ALL admission for the presence of ON-associated orthopedic surgical procedures.</p>

<p><strong>RESULTS: </strong>A cohort of 10,729 ALL patients was assembled, of which 242 (2.33%) were identified with an ICD-9 code for ON within 5 years of ALL diagnosis. Fifty-five patients (22.7%) with ON underwent orthopedic surgical intervention aimed at joint preservation (82%) or replacement (18%) with substantial practice variation by hospital in both the rate and type of surgical intervention. The majority of patients had surgical procedures while receiving maintenance therapy. None of the patients undergoing surgical intervention required intensive care unit-level care within 14 days of surgery, and there was no associated in-hospital mortality.</p>

<p><strong>CONCLUSIONS: </strong>No standard of care exists for treatment of ALL-associated ON. While considerable practice variation exists, surgical intervention appears relatively safe.</p>

DOI

10.1016/j.clml.2015.12.009

Alternate Title

Clin Lymphoma Myeloma Leuk

PMID

27021949

Title

Prioritization of comparative effectiveness research topics in hospital pediatrics.

Year of Publication

2012

Number of Pages

1155-64

Date Published

2012 Dec

ISSN Number

1538-3628

Abstract

<p><strong>OBJECTIVE: </strong>To use information about prevalence, cost, and variation in resource utilization to prioritize comparative effectiveness research topics in hospital pediatrics.</p>

<p><strong>DESIGN: </strong>Retrospective analysis of administrative and billing data for hospital encounters.</p>

<p><strong>SETTING: </strong>Thirty-eight freestanding US children's hospitals from January 1, 2004, through December 31, 2009.</p>

<p><strong>PARTICIPANTS: </strong>Children hospitalized with conditions that accounted for either 80% of all encounters or 80% of all charges.</p>

<p><strong>MAIN OUTCOME MEASURES: </strong>Condition-specific prevalence, total standardized cost, and interhospital variation in mean standardized cost per encounter, measured in 2 ways: (1) intraclass correlation coefficient, which represents the fraction of total variation in standardized costs per encounter due to variation between hospitals; and (2) number of outlier hospitals, defined as having more than 30% of encounters with standardized costs in either the lowest or highest quintile across all encounters.</p>

<p><strong>RESULTS: </strong>Among 495 conditions accounting for 80% of all charges, the 10 most expensive conditions accounted for 36% of all standardized costs. Among the 50 most prevalent and 50 most costly conditions (77 in total), 26 had intraclass correlation coefficients higher than 0.10 and 5 had intraclass correlation coefficients higher than 0.30. For 10 conditions, more than half of the hospitals met outlier hospital criteria. Surgical procedures for hypertrophy of tonsils and adenoids, otitis media, and acute appendicitis without peritonitis were high cost, were high prevalence, and displayed significant variation in interhospital cost per encounter.</p>

<p><strong>CONCLUSIONS: </strong>Detailed administrative and billing data can be used to standardize hospital costs and identify high-priority conditions for comparative effectiveness research--those that are high cost, are high prevalence, and demonstrate high variation in resource utilization.</p>

DOI

10.1001/archpediatrics.2012.1266

Alternate Title

Arch Pediatr Adolesc Med

PMID

23027409

Title

Variation in resource use and readmission for diabetic ketoacidosis in children's hospitals.

Year of Publication

2013

Number of Pages

229-36

Date Published

2013 Aug

ISSN Number

1098-4275

Abstract

<p><strong>OBJECTIVE: </strong>We sought to characterize variation in hospital resource utilization and readmission for diabetic ketoacidosis (DKA) across US children's hospitals.</p>

<p><strong>METHODS: </strong>The study sample included a retrospective cohort of children aged 2 to 18 years with a diagnosis of DKA at 38 children's hospitals between 2004 and 2009. The main outcomes were resource utilization as determined by total standardized cost per hospitalization, overall and non-ICU length of stay (LOS), and readmission for DKA within 30 and 365 days.</p>

<p><strong>RESULTS: </strong>There were 24,890 DKA admissions, and 20.3% of these were readmissions within 1 year. The mean hospital-level total standardized cost was $7142 (range $4125-$11,916). The mean hospital-level LOS was 2.5 days (1.5-3.7), and the non-ICU portion was 1.9 days (0.7-2.7). The mean hospital-level readmission within 365 days was 18.7% (6.5%-41.1%) and within 30 days was 2.5% (0.0%-7.1%). Hospital bed days overall, and in particular the non-ICU portion, accounted for the majority of the total standardized cost per hospitalization (overall 57%; non-ICU 36%) and explained most of the variation in resource use. Even after adjusting for difference in patient characteristics across hospitals, widespread differences existed across hospitals in total standardized cost, LOS, and readmission rates (P &lt; .001).</p>

<p><strong>CONCLUSIONS: </strong>Readmission for DKA within a year of hospitalization is common. US children's hospitals vary widely in resource use, hospital LOS, and readmission rates for patients with DKA. Our study highlights the need for additional research to understand these differences and to identify the most cost-effective strategies for managing diabetes across the continuum of care.</p>

DOI

10.1542/peds.2013-0359

Alternate Title

Pediatrics

PMID

23878044

Title

Perioperative antibiotic use for spinal surgery procedures in US children's hospitals.

Year of Publication

2013

Number of Pages

609-16

Date Published

2013 Apr 1

ISSN Number

1528-1159

Abstract

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using the Pediatric Health Information System database.</p>

<p><strong>OBJECTIVE: </strong>To describe longitudinal patterns of prophylactic antibiotic use and determinants of antibiotic choice for spinal fusion surgical procedures performed at US children's hospitals.</p>

<p><strong>SUMMARY OF BACKGROUND DATA: </strong>Surgical site infections (SSIs) account for a significant proportion of post-spinal surgery complications, particularly among children with complex conditions such as neuromuscular disease. Antimicrobial prophylaxis with intravenous cefazolin or cefuroxime has been a standard practice, but postoperative infections caused by organisms resistant to these antibiotics are increasing in prevalence. Studies describing the choice of antibiotic prophylaxis for pediatric spinal surgery are lacking.</p>

<p><strong>METHODS: </strong>We included children 6 months to 18 years of age discharged from 37 US children's hospitals between January 1, 2006, and June 30, 2009, with (1) an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) procedure code indicating a spinal fusion and (2) combinations of diagnosis codes indicating adolescent idiopathic scoliosis (AIS) (n = 5617) or neuromuscular scoliosis (NMS) (n = 3633). After identifying antibiotics ordered on the operative day, we described variation in broad-spectrum antibiotic use over time and measured associations between patient/surgery characteristics and antibiotic choice.</p>

<p><strong>RESULTS: </strong>Prophylactic antibiotic choice varied across hospitals and over time. Broad-spectrum antibiotics were used in 37% of AIS and 52% of NMS operations. Seven (19%) hospitals used broad-spectrum coverage for more 80% of all cases. For NMS procedures, broad-spectrum antibiotic use was associated with patient characteristics known to be associated with high SSI risk. Use of vancomycin and broad gram-negative agents increased over time.</p>

<p><strong>CONCLUSION: </strong>Broad-spectrum antimicrobial prophylaxis varied across hospitals and was often associated with known risk factors for SSI. These results highlight the need for future studies comparing the effectiveness of various prophylaxis strategies, particularly in high-risk subgroups. This research can inform the development of best practice for SSI prevention in spinal fusion procedures.</p>

DOI

10.1097/BRS.0b013e318289b690

Alternate Title

Spine

PMID

23370689

Title

Antifibrinolytic Use and Blood Transfusions in Pediatric Scoliosis Surgeries Performed at US Children's Hospitals.

Year of Publication

2015

Number of Pages

E460-6

Date Published

2015 Oct

ISSN Number

1539-2465

Abstract

<p><strong>STUDY DESIGN: </strong>Retrospective cohort study using the Pediatric Health Information Systems database.</p>

<p><strong>OBJECTIVE: </strong>To determine the association between antifibrinolytic use and red cell transfusions in spinal fusion operations performed at 37 US Children's Hospitals.</p>

<p><strong>SUMMARY OF BACKGROUND DATA: </strong>Evidence from randomized clinical trials and systematic reviews suggests that antifibrinolytic therapy can significantly reduce blood loss in children undergoing scoliosis surgery; however, the effectiveness of these agents as used in surgeries performed at US children's has not been studied.</p>

<p><strong>MATERIALS AND METHODS: </strong>We included children aged 0-18 years with diagnoses indicating adolescent idiopathic scoliosis (AIS) or neuromuscular scoliosis (NMS) for whom a spinal fusion procedure was performed between January 1, 2006 and September 30, 2009. Patients with malignancy, trauma, coagulation disorders, or for whom a cell salvage device was employed were excluded. Multilevel logistic regression was used to determine associations between ε-aminocaproic acid (EACA), tranexamic acid (TXA), and aprotinin (APR) use and blood transfusions, controlling for patient and surgery characteristics.</p>

<p><strong>RESULTS: </strong>Cohorts consisted of 2722 AIS and 1547 NMS procedures. Antifibrinolytic use varied across hospitals (AIS 3.3%, interquartile range, 0%-42%; NMS 12 interquartile range, 0%-46%), and was significantly associated with NMS, posterior fusion, number of vertebrae fused. Overall, 15% of children received EACA, 7% TXA, and 2% APR. The median hospital-specific rate of red cell transfusions was 24% for AIS and 43% for NMS. In AIS operations, EACA use, but not TXA use, was associated with significantly lower odds of transfusion (odds ratio, 0.42; P&lt;0.001 vs. odds ratio, 1.0; P=0.8). In NMS operations, neither EACA nor TXA use was associated with a decrease in odds of red cell transfusions.</p>

<p><strong>CONCLUSIONS: </strong>The effectiveness of antifibrinolytics as used outside of clinical trials is unclear and should continue to be explored. Future prospective research is needed to evaluate which administration protocols will most benefit patients, as well as to determine the comparative effectiveness of these drugs in the context of other blood conservation strategies.</p>

DOI

10.1097/BSD.0b013e3182a22a54

Alternate Title

J Spinal Disord Tech

PMID

24091932

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