Crayton A. Fargason

Strategies for the Prevention of Early-onset Neonatal Group B Streptococcal Sepsis: A Decision Analysis

Objective: To perform a decision analysis to understand better the implications of 19 potential group B streptococcus screening and treatment strategies. Methods: We searched the literature to locate appropriate articles from which to derive probability estimates. Using decision analysis, we determined the likely outcomes of 19 group B streptococcus screening and treatment strategies and focused on three main outcomes: 1) number of expected cases of early‐onset neonatal group B streptococcal sepsis, 2) percentage of gravidas treated with intrapartum antibiotics, and 3) total costs. Results: The strategy recently recommended by two committees of the American Academy of Pediatrics (universal 28‐week maternal rectovaginal group B streptococcal culture and treatment of culture‐positive, high‐risk patients in labor) is among the least effective at reducing neonatal sepsis and the most costly. Strategies based on the currently available rapid streptococcus identification tests are ineffective at reducing neonatal sepsis and are costly. Three strategies outperform the rest: 1) Universal intrapartum maternal antibiotic treatment is the most effective strategy in reducing early‐onset neonatal group B streptococcal sepsis (6% of expected) and is also the least costly; 2) intrapartum treatment based solely on risk factors (recently endorsed by ACOG) lowers the rate of neonatal sepsis to 31% of expected with an 18% maternal treatment rate and low total costs; and 3) universal 36‐week maternal culture, and treatment of all patients experiencing preterm birth and all culture‐positive patients results in 14% of expected neonatal sepsis, with a 27% maternal treatment rate and low total costs. Conclusion: Given the present state of knowledge, three strategies emerge from this decision analysis as most optimal for the prevention of early‐onset neonatal group B streptococcal sepsis: universal treatment, treatment based on risk factors, and treatment based on preterm delivery and 36‐week culture status. (Obstet Gynecol 1994;83:483‐94)

How Well Can Hospital Readmission Be Predicted in a Cohort of Hospitalized Children? A Retrospective, Multicenter Study

BACKGROUND. Children with complex chronic conditions depend on both their families and systems of pediatric health care, social services, and financing. Investigations into the workings of this ecology of care would be advanced by more accurate methods of population-level predictions of the likelihood for future hospitalization. METHODS. This was a retrospective cohort study. Hospital administrative data were collected from 38 childrens hospitals in the United States for the years 2003–2005. Participants included patients between 2 and 18 years of age discharged from an index hospitalization during 2004. Patient characteristics documented during the index hospitalization or any previous hospitalization during the preceding 365 days were included. The main outcome measure was readmission to the hospital during the 365 days after discharge from the index admission. RESULTS. Among the cohort composed of 186856 patients discharged from the participating hospitals during 2004, the mean age was 9.2 years, with 54.4% male and 52.9% identified as non-Hispanic white. A total of 17.4% were admitted during the previous 365 days, and among those discharged alive (0.6% died during the admission), 16.7% were readmitted during the ensuing 365 days. The final readmission model exhibited a c statistic of 0.81 across all hospitals, with a range from 0.76 to 0.84 for each hospital. Bootstrap-based assessments demonstrated the stability of the final model. CONCLUSIONS. Accurate population-level prediction of hospital readmissions is possible, and the resulting predicted probability of hospital readmission may prove useful for health services research and planning.

Do local opinion leaders augment hospital quality improvement efforts? A randomized trial to promote adherence to unstable angina guidelines

Background. The influence of an opinion leader intervention on adherence to Unstable Angina (UA) guidelines compared with a traditional quality improvement model was investigated. Research Design. A group-randomized controlled trial with 2210 patients from 21 hospitals was designed. There were three intervention arms: (1) no intervention (NI); (2) a traditional Health Care Quality Improvement Program (HCQIP); and (3) a physician opinion leader in addition to the HCQIP model (OL). Quality indicators included: electrocardiogram within 20 minutes, antiplatelet therapy within 24 hours and at discharge, and heparin and &bgr;-blockers during hospitalization. Hospitals could determine the specific indicators they wished to target. Potential cases of UA were identified from Medicare claims data. UA confirmation was determined by a clinical algorithm based on data abstracted from medical records. Data analyses included both hospital level analysis (analysis of variance) and patient level analysis (generalized linear models). Results. The only statistically significant postintervention difference in percentage compliant was greater improvement for the OL group in the use of antiplatelet therapy at 24 hours in both hospital level (P = 0.01) and patient level analyses (P <0.05) compared with the HCQIP and NI groups. When analyses were confined to hospitals that targeted specific indicators, compared with the HCQIP hospitals, the OL hospitals showed significantly greater change in percentage compliant postintervention in both antiplatelet therapy during the first 24 hours (20.2% vs. −3.9%, P = 0.02) and heparin (31.0% vs.9.1%, P = 0.05). Conclusions. The influence of physician opinion leaders was unequivocally positive for only one of five quality indicators. To maximize adherence to best practices through physician opinion leaders, more research on how these physicians influence health care delivery in their organizations will be required.

Compliance With Vision-Screening Guidelines Among a National Sample of Pediatricians

OBJECTIVE The American Academy of Pediatrics (AAP) recommends vision screening from birth through adolescence, with visual acuity testing and binocular screening to begin at age 3 years. The 1996 AAP guidelines advised referral for visual acuity worse than 20/40 for children aged 3 to 5 years and worse than 20/30 for children aged 6 years and older. Our objective was to describe vision-screening and referral practices in a national sample of primary care pediatricians. METHODS We mailed a survey to a random sample of US pediatricians. Initial nonresponders were mailed up to 3 additional surveys. All mailings occurred between May and October 1998. Analyses focused on primary care pediatricians and consisted of descriptive statistics and regression analyses. The main outcome measure was compliance with 1996 AAP recommendations for vision screening. RESULTS Of the 1491 surveys mailed, 888 (60%) were returned, including 576 (65%) from primary care pediatricians. Vision-screening methods included visual acuity testing (92%), cover test (64%), red reflex test (95%), fundoscopic examinations (65%), and stereopsis testing (32%). Respondents routinely performed visual acuity testing at 3 years (37%), 4 years (79%), 5 years (91%), 6 years (80%), 7-12 years (82%), and 13-18 years (80%). Visual acuity thresholds for referring 3- and 4-year-olds were 20/40 (47%, 51%), 20/50 (36%, 32%), or worse than 20/50 (14%, 12%). The majority of pediatricians referred children aged 5 years and older at 20/40, although thresholds worse than 20/40 were reported commonly (18%-33%). Logistic regressions were done to identify factors associated with higher likelihood of performing specific screening tests. Although no factor was consistently associated with use of all screening tests, size of the practice was significant in several regression models. CONCLUSIONS Many pediatricians do not follow AAP guidelines for vision screening and referral, especially in younger children. Two thirds of pediatricians do not begin visual acuity testing at age 3 years as recommended, and about one fifth do not test until age 5 years. In addition, one fourth do not perform cover tests or stereopsis testing at any age.

The pediatric costs of strategies for minimizing the risk of early-onset group B streptococcal disease.

Objective To estimate the pediatric costs associated with the Centers for Disease Control and Prevention (CDC) guidelines for the management of infants born to mothers receiving intrapartum antimicrobial prophylaxis for prevention of early-onset group B streptococcal disease. Methods For an annual United States birth cohort of 3.95 million infants, we estimated the cost of pediatric care provided to full-term asymptomatic infants when pediatricians followed the CDC algorithm for the management of infants exposed to intrapartum antimicrobial prophylaxis under culture-based and risk factor-based maternal care approaches. We calculated the relative contribution of pediatric costs to the total costs of preventing a case of earlyonset group B streptococcal sepsis. Results Total pediatric costs were

Cross–Functional, Integrative Team Decision Making: Essential for Effective QI in Health Care

41 million for a culture-based approach and

Moving Hospitalized Children All Over the Southeast: Interstate Transfer of Pediatric Patients During Hurricane Katrina

33 million for a risk factor-based approach. Hospital and physician costs accounted for more than 78% of this total. The majority (over 95%) of the pediatric costs were associated with vaginal deliveries. Incorporating pediatric costs into previous cost-effectiveness analyses increased the cost per sepsis case averted by as much as 51% for culture-based strategies and by as much as 112% for risk factor-based strategies. Pediatric costs varied with the average length of stay for full-term infants and with the average cost of a hospital day. Conclusion Substantial pediatric costs are associated with the implementation of an obstetric strategy for minimizing the risk of early-onset group B streptococcal disease. Such costs should be included in future cost-effectiveness analyses of different strategies for minimizing the risk of group B streptococcal disease in newborns.

Attitudes of Academic Pediatricians With a Specific Interest in Child Abuse Toward the Spanking of Children

Quality improvement methods first developed in industry can be applied in health care, but major adjustments in the traditional health care organization are needed for continuous improvement processes to work. One change is establishing cross-functional or multidisciplinary teams to carry out integrative decision making in the place of departmental hierarchical decision making within the functional areas and disciplines. This article cites examples from experience with one service process--delivery of care to newborns--and examines techniques from the group behavior and conflict resolution literature which could enhance the success of cross-functional teams in health care organizations.

Limitations of the current child sexual abuse medical literature from a Bayesian perspective

RACTICAL QUESTIONS: The question was, and is, “Can hospitalized children, in a geographic area, have their continuing medical needs met when capacity in that geographic area to provide care is exceeded?” Events after the landfall of Hurricane Katrina on the city of New Orleans, Louisiana, generated significant information about pediatric care delivery during a disaster. In particular, Katrina helped answer 3 key questions regarding the care of children under disaster conditions: 1. In a disaster, will regional capabilities be used to augment local capabilities to care for children? In particular, will there be a preference for bypassing nearby providers of adult care to send pediatric patients to more specialized pediatric care facilities that are more geographically distant? 2. Can the communication and logistic challenges associated with regional pediatric patient movement be overcome during a disaster? 3. Do government disaster plans at the local, state, and federal levels facilitate pediatric patient movement across jurisdictions during a disaster? We will provide a chronological timeline of pediatric activities related to the care of patients in 3 New Orleans hospitals (Tulane University Hospital, Childrens Hospital of New Orleans, and Alton Ochsner Foundation Hospital) at the time of Katrinas landfall. After outlining the relevant sequence of activities, we will relate these activities to the 3 questions posed above. Our discussion focuses on New Orleans, because it is an urban center with the highest concentration of pediatric inpatients that were impacted by Katrina. Our timeline is based on selected interviews and publicly available information. Despite the biased, qualitative, and focused nature of the analysis, the New Orleans experience demonstrates the need for significant adjustments in our disaster plans for pediatric care during disasters. Ironically, pediatric health care providers from 5 states had been participating in the Southeastern Regional Pediatric Disaster Response Network for 1 year before Hurricane Katrina in … Address correspondence to Crayton A. Fargason, MD, Childrens Hospital of Alabama, ACC Suite 512, 1600 7th Ave S, Birmingham, AL 35233. E-mail: crayton.fargason{at}peds.uab.edu

Quality in the Interorganizational Setting

OBJECTIVE To evaluate the attitudes of academic child abuse professionals toward spanking, the effect of context and mode of administration on their attitudes toward spanking appropriateness, and what they teach residents about spanking. DESIGN A survey. PARTICIPANTS Convenience sample of 114 members of the Ambulatory Pediatric Associations Special Interest Group on Child Abuse and Neglect. MAIN OUTCOME MEASURES Respondents were asked if spanking was an appropriate disciplinary option for children 2, 5, and 8 years of age who refused to go to bed, ran into the streets without looking, or hit a playmate. Respondents also rated the appropriateness of spanking in 6 additional scenarios where the setting in which spanking occurred was varied. Respondents teaching practices relative to spanking observed during a clinic visit were also elicited. RESULTS The response rate was 70%; 39% thought spanking was appropriate sometimes. The context and mode of spanking affected the acceptance of spanking. All respondents thought that some response was appropriate when spanking was observed during a continuity clinic visit. However, only 29% of respondents taught residents how to handle such situations. CONCLUSIONS Most academic child abuse professionals believe that spanking is inappropriate and their beliefs are influenced by the context in which spanking occurs. Little is taught about how to manage spanking observed in a clinical setting.