Anne M. Gadomski

Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis

This guideline is a revision of the clinical practice guideline, “Diagnosis and Management of Bronchiolitis,” published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Updated Guidance for Palivizumab Prophylaxis Among Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection

Palivizumab was licensed in June 1998 by the Food and Drug Administration for the reduction of serious lower respiratory tract infection caused by respiratory syncytial virus (RSV) in children at increased risk of severe disease. Since that time, the American Academy of Pediatrics has updated its guidance for the use of palivizumab 4 times as additional data became available to provide a better understanding of infants and young children at greatest risk of hospitalization attributable to RSV infection. The updated recommendations in this policy statement reflect new information regarding the seasonality of RSV circulation, palivizumab pharmacokinetics, the changing incidence of bronchiolitis hospitalizations, the effect of gestational age and other risk factors on RSV hospitalization rates, the mortality of children hospitalized with RSV infection, the effect of prophylaxis on wheezing, and palivizumab-resistant RSV isolates. This policy statement updates and replaces the recommendations found in the 2012 Red Book.

Impact of a Medicaid Primary Care Provider and Preventive Care on Pediatric Hospitalization

Objective. This study evaluates the impact that a Medicaid managed care program had on avoidable hospitalization, a form of health care misuse that we hypothesize can be reduced by improved access to and quality of primary care in the context of a managed care program. Ambulatory care sensitive (ACS) hospitalizations, a previously defined categorization of hospitalization, as well as all pediatric hospitalizations were also studied. Intervention. The Maryland Access to Care (MAC) was a fee-for-service, gatekeeper, Medicaid managed care program with assigned primary medical providers and required Early Periodic Screening, Diagnosis, and Treatment (EPSDT) examinations. Medicaid managed care elements include: 1) assignment to primary medical provider (PMP) either by voluntary choice or mandatory enrollment of eligible Aid to Families With Dependent Children (AFDC), Medical Assistance (medical needy), and Supplemental Security Income; 2) a medical home accessible 24 hours a day, 7 days a week; 2) PMP must authorize emergency department (ED), inpatient, and specialty care but there were no disincentives to PMP for referral; 3) fee-for-services reimbursement (with a physician rate increase) for primary care, authorized specialist care, and hospitalization; and 4) an on-line eligibility verification system was available to all medical providers. Pre-enrollment as well as publicity allowed MAC to be phased in rapidly, resulting in 70% to 80% enrollment by the end of the first program year. Design. The design of this study is that of a pre- and postevaluation of the MAC program using Medicaid claims analysis of data 3 years pre-MAC and 2 years post-MAC. In multivariate analyses, this study also compares MAC-enrolled children to non–MAC-enrolled children (before and after MAC began) to estimate the impact of MAC enrollment while controlling for potential confounders. Setting. State of Maryland from 1989 to 1993. Patients. MAC-eligible children ≤18 years of age. Outcome Measures. Claims data were used to define avoidable hospitalization (based on ambulatory care received before hospitalization), to define ACS hospitalizations (based on theInternational Classification of Diseases–Clinical Modification, Ninth Revision [ICD-9-CM] codes), and to summarize use of ambulatory and inpatient care. Avoidable hospitalizations include those conditions for which evidence exists that specific ambulatory care modalities reduce hospitalization rates. These hospitalizations were defined by combining the first ICD-9-CM on an inpatient claim with ambulatory and/or pharmacy claims for services before that hospitalization. The criterion of preceding ambulatory care was applied by linking dates of admission to hospital with ambulatory service dates. An example of an avoidable hospitalization is a hospitalization for asthma (ICD-9-CM = 493) that has no antecedent pharmacy claim for steroids. ACS hospitalizations have been defined as those conditions for which timely and effective primary care can help to reduce the risk of hospitalizations. These are based solely on ICD-9-CM discharge codes that were studied by Billings and Teicholz 11 in 1990 and used by an Institute of Medicine report 12 in 1993. Examples include hospital discharge diagnoses of asthma (ICD-9-CM = 493), gastroenteritis (ICD-9-CM = 558.9), and dehydration (ICD-9-CM = 276.5). Usage measures, such as preventive care visits or ED visits, were created using Maryland Medicaid codes, Current Procedural Terminology codes, and ICD-9-CM codes. Linear regression was used to model trend. Logistic regression was used to model the probability of ambulatory and inpatient care given MAC enrollment and other covariates. First, logistic regression was used to predict the probability of any ambulatory care use among all MAC-eligible children during a quarter to model changes in access that may have occurred during MAC. Then, among users of ambulatory care or inpatient care, logistic regression was used to predict the probability of hospitalization. Results. Most of the children studied were in the AFDC program, about half were African-American, one third resided in Baltimore City, and 9% of children had ICD-9-CMs reflecting chronic disease. The mean percentage of time children were MAC-eligible per quarter was 91%. Only 5% of children were continuously enrolled for all 20 quarters included in this study. Per-capita ambulatory care visits, especially per-capita preventive care visits, increased significantly during the study period (b = 0.003) whereas per-capita ED visits did not change. The mean number of preventive visits was 0.2 visits/quarter for MAC-enrolled children compared with 0.1 visits/quarter for nonenrolled children. Although the mean number of ED visits was the same (0.06 visits/quarter) during the pre- and post-MAC periods, the mean number of ED visits for MAC-enrolled children was slightly higher than nonenrolled children (0.065 versus 0.057 visits per quarter). Because multiple factors affect use, multivariate analysis was used to adjust for potential confounders. With all 3.2 million child-quarter observations included in the regression, MAC enrollment (odds ratio [OR] = 2.2, 95% confidence interval [CI] = 2.17–2.22) was strongly associated with the probability of any preventive care visits (1 or more). MAC enrollment was also associated with an increased probability of any ED use (OR = 1.4, 95% CI = 1.42–1.46) or any ambulatory care visit (OR = 2.58, 95% CI = 0.57–2.60). Among those children who used ambulatory care (1.2 million child-quarters), MAC enrollment was associated with a lower probability of avoidable (OR = 0.89, 95% CI = 0.83–0.97) and any hospitalization (OR = 0.81, 95% CI = 0.79–0.84), but no change in ACS hospitalization (OR = 0.96, 95% CI = 0.92–1.01). With multiple hospitalizations per quarter excluded, MAC enrollment was associated with a reduced probability of avoidable (OR = 0.86, 95% CI = 0.80–0.93), ACS (OR = 0.93, 95% CI = 0.88–0.98), and any pediatric hospitalization (OR = 0.79, 95% CI = 0.76–0.81). The probability of an avoidable hospitalization was inversely related to the number of preventive care visits (OR = 0.70, 95% CI = 0.67–0.74) and directly related to ED visits (OR = 2.11, 95% CI = 2.06–2.16). Conclusions. Enrollment in the MAC program and preventive care were associated with a reduced probability of avoidable as well as any pediatric hospitalization. Given the strong association between preventive care and reduced probability of hospitalization, it is likely that MAC exerts a positive effect on hospitalization through augmented preventive care, ie, numbers of preventive care visits, required EPSDT, increased access, and provider continuity. Further research is needed to document the clinical effectiveness of preventive care for children.

Improving Child and Parent Mental Health in Primary Care: A Cluster-Randomized Trial of Communication Skills Training

OBJECTIVE. We examined child and parent outcomes of training providers to engage families efficiently and to reduce common symptoms of a range of mental health problems and disorders. METHODS. Training involved three 1-hour discussions structured around video examples of family/provider communication skills, each followed by practice with standardized patients and self-evaluation. Skills targeted eliciting parent and child concerns, partnering with families, and increasing expectations that treatment would be helpful. We tested the training with providers at 13 sites in rural New York, urban Maryland, and Washington, DC. Children (5–16 years of age) making routine visits were enrolled if they screened “possible” or “probable” for mental disorders with the Strengths and Difficulties Questionnaire or if their provider said they were likely to have an emotional or behavioral problem. Children and their parents were then monitored for 6 months, to assess changes in parent-rated symptoms and impairment and parent symptoms. RESULTS. Fifty-eight providers (31 trained and 27 control) and 418 children (248 patients of trained providers and 170 patients of control providers) participated. Among the children, 72% were in the possible or probable categories. Approximately one half (54%) were white, 30% black, 12% Latino, and 4% other ethnicities. Eighty-eight percent (367 children) completed follow-up monitoring. At 6 months, minority children cared for by trained providers had greater reduction in impairment (−0.91 points) than did those cared for by control providers but no greater reduction in symptoms. Seeing a trained provider did not have an impact on symptoms or impairment among white children. Parents of children cared for by trained providers experienced greater reduction in symptoms (−1.7 points) than did those cared for by control providers. CONCLUSION. Brief provider communication training had a positive impact on parent mental health symptoms and reduced minority childrens impairment across a range of problems.

Clinical trial of vitamin A as adjuvant treatment for lower respiratory tract infections

OBJECTIVE To test the efficacy of a high dose of vitamin A as adjuvant treatment for radiographically confirmed cases of acute lower respiratory tract infection (ALRI). DESIGN Randomized, double-masked, placebo-controlled clinical trial. SETTING Two large urban hospitals in Guatemala City. PATIENTS Sequential sample of 263 children aged 3 to 48 months, identified in the emergency departments and admitted to the hospital. INTERVENTIONS Vitamin A (100,000 IU for children less than 1 year of age, and 200,000 IU for older children) or placebo in addition to standard treatment for ALRI which included antibiotics, oxygen, bronchodilators, and intravenously administered solutions. MEASUREMENTS AND MAIN RESULTS The children were assessed every 8 hours. There were neither statistically nor clinically significant differences by treatment group in the rate of normalization in respiratory rate, oxygen saturation, temperature, or clinical score. Duration of hospitalization was not different by treatment group. Adverse outcomes (mechanical ventilation, prolonged hospitalization, readmission or transfer, and death) were equally distributed between the two groups. CONCLUSIONS Treatment with high doses of vitamin A over and above standard care for infants and children with non-measles-related ALRI is not efficacious for the current episode. Additional trials among populations in which vitamin A deficiency is more prevalent and severe should be considered.

Oral versus nebulized albuterol in the management of bronchiolitis in Egypt

The efficacy of albuterol in the management of infants with first-time wheezing is controversial. This double-blind, placebo-controlled trial involved 128 Egyptian infants with first-time wheezing (mean age 5.9 months) who were randomly separated into four equivalent therapy groups: nebulized albuterol, nebulized saline solution, orally administered albuterol, and orally administered placebo. The nebulized therapy groups received two treatments 30 minutes apart; the oral therapy groups received one treatment. In addition, 41 infants with recurrent wheezing comprised an open-label control group who received two albuterol nebulizations. Chest radiographs, leukocyte counts, blood culture specimens, and nasal aspirate for viral antigen detection were obtained to confirm the clinical diagnosis of viral bronchiolitis. Respiratory and heart rates, clinical score, and oxygen saturation were recorded at baseline and 30 and 60 minutes after treatment. There was no difference among the four randomized groups in any of the outcomes except for an increase in heart rate of 10 beats/min in the nebulized albuterol group compared with a decrease in heart rate of 8 beats/min in the oral placebo group. No differences in the need for additional treatment were observed. Nebulized albuterol significantly improved the clinical score and reduced the respiratory rate of those with recurrent wheezing relative to those in the randomized groups. We conclude that nebulized albuterol is effective in the treatment of infants with recurrent wheezing, but there was no demonstrable efficacy of orally administered or nebulized albuterol in relieving the respiratory distress of infants with bronchiolitis in Egypt.

Efficacy of the North American Guidelines for Children’s Agricultural Tasks in Reducing Childhood Agricultural Injuries

OBJECTIVES We assessed whether active dissemination of the North American Guidelines for Childrens Agricultural Tasks (NAGCAT) reduced childhood agricultural injuries. METHODS In this randomized controlled trial, lay educators visited intervention farms to review NAGCAT. New York State farms with resident or working children were randomized. Control farms were visited only to collect baseline data. Data on childhood injuries, tasks, and hours worked were obtained quarterly for 21 months. Injury rates per farm were compared between the treatment and control groups, along with time span to occurrence of an injury and to violation of NAGCAT age guidelines. RESULTS Intervention farms were less likely than control farms to violate NAGCAT age guidelines in the areas of all-terrain-vehicle use and tractor and haying operations. Cox proportional hazards regression models showed a significant protective effect of the intervention on preventable injuries after adjustment for important covariates. CONCLUSIONS Our results showed that dissemination of NAGCAT reduced rates of work-related childhood agricultural injuries. A comprehensive public health approach is needed to reduce non-work-related childhood injuries.

Aspects of mental health communication skills training that predict parent and child outcomes in pediatric primary care.

OBJECTIVE Training in communication can change clinician behaviors, but brief training may function by altering attitudes rather than teaching new skills. We used data from a trial of mental health training for office-based primary care to determine indicators of uptake that predicted parent and child outcomes. METHODS Clinicians (n=50) were randomized to be controls or receive training. Uptake was determined comparing pre- and post-training visits with standardized patients (SPs) coded for skills and patient centeredness. Clinical outcomes were assessed by recruiting and following 403 children/youth ages 5-16 making visits to participants. At 6 months, change in mental health was assessed by parent and youth reports using the Strengths and Difficulties Questionnaire. RESULTS Trained clinicians used more agenda setting, time, and anger management skills than controls and showed increased patient centeredness toward SP parents, but not adolescents. Increased patient-centeredness toward parents predicted improvement in child/youth symptoms and functioning (rated by parents), and improvement in youth-rated symptoms. Increased skills alone were not associated with improvement, but patients of clinicians above the mean for both skill and patient-centeredness change improved most.

Implementing a smoke-free medical campus: Impact on inpatient and employee outcomes†‡

BACKGROUND Hospitals fear that transitioning to a smoke-free medical campus will decrease patient volume, particularly for patients who smoke. When our hospital campus, a 180-bed acute care facility located in a small town, implemented the smoke-free medical campus on July 1, 2006, we prospectively monitored inpatient and employee outcomes. METHODS Inpatient volume, percentage of inpatients who currently smoke, nicotine replacement therapy (NRT) orders (obtained from electronic medical records), the number of inpatients who signed out against medical advice (obtained from incident reports), and employee tobacco-use rates from annual occupational health assessments were compared pre-ban and post-ban. RESULTS The monthly average for the percentage of inpatients who currently smoke has been steady, at 20% to 22% post-ban. NRT orders tripled after the ban. There was no significant change in the rate of inpatients who signed out against medical advice pre-ban and post-ban. During the year preceding the ban, 150 employees participated in a cessation program offered by Employee Health. The pre-ban employee self-reported smoking rate for the same 4-month period (March-June) was 14.3% in 2005, 14.8% in 2006, and 9% in 2007 (P < 0.0002). CONCLUSIONS Implementing a smoke-free medical campus did not adversely affect inpatient volume (even among smokers), significantly increased inpatient NRT use, and decreased hospital employee smoking rates.

Effectiveness of an inpatient smoking cessation program

BACKGROUND Inpatient smoking cessation may increase the success of quitting smoking post-hospital discharge. METHODS Using a quasiexperimental study design, use of cessation methods, mortality, self-reported abstinence, and quit status 6 months post-hospital discharge were measured to assess the effectiveness of an inpatient smoking cessation program. Subjects were interviewed by telephone 6 months post-hospital discharge. Outcomes for patients who were seen by the inpatient smoking cessation counselor were compared to consecutive patients who were not seen by the counselor. Electronic medical records (EMRs) and administrative data were used to construct baseline measures, comorbidity covariates, pharmaceutical use rates during hospitalization, readmission, and mortality outcomes. Multivariate methods included logistic regression and survival analysis. RESULTS At baseline, the study groups varied by mean age, length of stay (LOS), comorbidity index, cardiovascular diagnosis, and acuity. At 6 months post-hospital discharge, the intent to treat estimate for point prevalence abstinence was 16% in the intervention group compared to 10% in the comparison group (P = 0.02) while self-reported quit status in the intervention group was 44% vs. 30% in the comparison group (P = 0.00). The intervention group used more nicotine replacement therapy (NRT) than the comparison group both in-hospital and following discharge. Crude post-hospital discharge mortality was significantly less in the intervention group (0.02) than in the comparison group (0.04). A multivariate survival model, controlling for baseline imbalances, showed a significantly reduced mortality in the intervention group (hazard ratio [HR] = 0.37; P = 0.04). CONCLUSIONS Inpatient smoking cessation programs effectively improve quit outcomes, NRT use, and mortality post-hospital discharge.