Evaline A. Alessandrini

Impact of clinical alerts within an electronic health record on routine childhood immunization in an urban pediatric population.

OBJECTIVES. The objective of this study was to test the hypothesis that clinical alerts for routine pediatric vaccinations within an electronic health record would reduce missed opportunities for vaccination and improve immunization rates for young children in an inner-city population. METHODS. A 1-year intervention study (September 1, 2004, to August 31, 2005) with historical controls was conducted in 4 urban primary care centers affiliated with an academic medical center. All children who were younger than 24 months were enrolled. Electronic health record–based clinical reminders for routine childhood vaccinations were programmed to appear prominently at every patient encounter with vaccines due. The main outcome measures were rates of captured immunization opportunities and overall immunization rates at 24 months of age. RESULTS. Immunization alerts appeared at 15928 visits during the intervention. Alert implementation was associated with increases in captured immunization opportunities from 78.2% to 90.3% at well visits and from 11.3% to 32.0% at sick visits. Adjusted up-to-date immunization rates at 24 months of age increased from 81.7% to 90.1% from the control to intervention period. Children in the intervention group also became up-to-date earlier than control patients. Patient characteristics were stable throughout the study. CONCLUSIONS. An electronic health record–based clinical alert intervention was associated with increases in captured opportunities for vaccination at both sick and well visits and significant improvements in immunization rates at 2 years of age. As electronic health records become more common in medical practice, such systems may transform immunization delivery to children.

Oral versus intravenous rehydration of moderately dehydrated children: a randomized, controlled trial.

Background. Dehydration from viral gastroenteritis is a significant pediatric health problem. Oral rehydration therapy (ORT) is recommended as first-line therapy for both mildly and moderately dehydrated children; however, three quarters of pediatric emergency medicine physicians who are very familiar with the American Academy of Pediatrics recommendations for ORT still use intravenous fluid therapy (IVF) for moderately dehydrated children. Objective. To test the hypothesis that the failure rate of ORT would not be >5% greater than the failure rate of IVF. Secondary hypotheses were that patients in the ORT group will (1) require less time initiating therapy, (2) show more improvement after 2 hours of therapy, (3) have fewer hospitalizations, and (4) prefer ORT for future episodes of dehydration. Methods. A randomized, controlled clinical trial (noninferiority study design) was performed in the emergency department of an urban children’s hospital from December 2001 to April 2003. Children 8 weeks to 3 years old were eligible if they were moderately dehydrated, based on a validated 10-point score, from viral gastroenteritis. Patients were randomized to receive either ORT or IVF during the 4-hour study. Treating physicians were masked and assessed all patients before randomization at 2 and 4 hours of therapy. Successful rehydration at 4 hours was defined as resolution of moderate dehydration, production of urine, weight gain, and the absence severe emesis (≥5 mL/kg). Results. Seventy-three patients were enrolled in the study: 36 were randomized to ORT and 37 were randomized to IVF. Baseline dehydration scores and the number of prior episodes of emesis and diarrhea were similar in the 2 groups. ORT demonstrated noninferiority for the main outcome measure and was found to be favorable with secondary outcomes. Half of both the ORT and IVF groups were rehydrated successfully at 4 hours (difference: −1.2%; 95% confidence interval [CI]: −24.0% to 21.6%). The time required to initiate therapy was less in the ORT group at 19.9 minutes from randomization, compared with 41.2 minutes for the IVF group (difference: −21.2 minutes; 95% CI: −10.3 to −32.1 minutes). There was no difference in the improvement of the dehydration score at 2 hours between the 2 groups (78.8% ORT vs 80% IVF; difference: −1.2%; 95% CI: −20.5% to 18%). Less than one third of the ORT group required hospitalization, whereas almost half of the IVF group was hospitalized (30.6% vs 48.7%, respectively; difference: −18.1%; 95% CI: −40.1% to 4.0%). Patients who received ORT were as likely as those who received IVF to prefer the same therapy for the next episode of gastroenteritis (61.3% vs 51.4%, respectively; difference: 9.9%; 95% CI: −14% to 33.7%). Conclusions. This trial demonstrated that ORT is as effective as IVF for rehydration of moderately dehydrated children due to gastroenteritis in the emergency department. ORT demonstrated noninferiority for successful rehydration at 4 hours and hospitalization rate. Additionally, therapy was initiated more quickly for ORT patients. ORT seems to be a preferred treatment option for patients with moderate dehydration from gastroenteritis.

Impact of electronic health record-based alerts on influenza vaccination for children with asthma.

OBJECTIVE: The goal was to assess the impact of influenza vaccine clinical alerts on missed opportunities for vaccination and on overall influenza immunization rates for children and adolescents with asthma. METHODS: A prospective, cluster-randomized trial of 20 primary care sites was conducted between October 1, 2006, and March 31, 2007. At intervention sites, electronic health record-based clinical alerts for influenza vaccine appeared at all office visits for children between 5 and 19 years of age with asthma who were due for vaccine. The proportion of captured immunization opportunities at visits and overall rates of complete vaccination for patients at intervention and control sites were compared with those for the previous year, after standardization for relevant covariates. The study had >80% power to detect an 8% difference in the change in rates between the study and baseline years at intervention versus control practices. RESULTS: A total of 23 418 visits and 11 919 children were included in the study year and 21 422 visits and 10 667 children in the previous year. The majority of children were male, 5 to 9 years of age, and privately insured. With standardization for selected covariates, captured vaccination opportunities increased from 14.4% to 18.6% at intervention sites and from 12.7% to 16.3% at control sites, a 0.6% greater improvement. Standardized influenza vaccination rates improved 3.4% more at intervention sites than at control sites. The 4 practices with the greatest increases in rates (≥11%) were all in the intervention group. Vaccine receipt was more common among children who had been vaccinated previously, with increasing numbers of visits, with care early in the season, and at preventive versus acute care visits. CONCLUSIONS: Clinical alerts were associated with only modest improvements in influenza vaccination rates.

Return visits to a pediatric emergency department.

Objectives: To determine the incidence of return visits (RVs), types of RVs, and factors associated with RVs to a pediatric emergency department (ED). Methods: Retrospective cohort study of patients seen in an urban, tertiary care pediatric ED. Main outcome: RV within 48 hours, identified from a computerized log. Results: The total RV rate was 3.5% (95% confidence interval, 3.3-3.6), similar to rates (2.4% to 3.4%) reported in general EDs. Most (78.5%) RVs were unscheduled, 17% were scheduled, and 4% were called back to the ED. Infectious disease (45%), respiratory (16%), and trauma (16%) accounted for most RV diagnoses. When compared with the overall ED population, RV patients were more likely to be younger than 2 years [relative risk, 1.3 (1.2-1.4)], to be admitted to the hospital [relative risk, 1.3 (1.2-1.5)], and to be triaged as acute [relative risk, 1.1 (1.0-1.2)]. Patients called back to the ED were younger, more likely to be triaged as acute, and more likely to be admitted than other RV patients. Significant diagnoses were made at RV in 7 (0.4%; 95% confidence interval, 0.1-0.7) patients, half of whom were called back to the ED or had a scheduled RV. Conclusion: Similarities between our pediatric ED RV rate and other published research implies that benchmarking and quality improvement tools for RV can be used and compared in both pediatric and general EDs. Focusing on systems to call patients back to the ED when necessary may be an efficient way to reduce medical error and adverse patient outcomes.

Shared Decision-Making in Pediatrics: A National Perspective

OBJECTIVES: To identify patterns of shared decision-making (SDM) among a nationally representative sample of US children with attention-deficit/hyperactivity disorder (ADHD) or asthma and determine if demographics, health status, or access to care are associated with SDM. PATIENTS AND METHODS: We performed a cross-sectional study of the 2002–2006 Medical Expenditure Panel Survey, which represents 2 million children with ADHD and 4 million children with asthma. The outcome, high SDM, was defined by using latent class models based on 7 Medical Expenditure Panel Survey items addressing aspects of SDM. We entered factors potentially associated with SDM into logistic regression models with high SDM as the outcome. Marginal standardization then described the standardized proportion of childrens households with high SDM for each factor. RESULTS: For both ADHD and asthma, 65% of childrens households had high SDM. Those who reported poor general health for their children were 13% less likely to have high SDM for ADHD (64 vs 77%) and 8% less likely for asthma (62 vs 70%) when adjusting for other factors. Results for behavioral impairment were similar. Respondent demographic characteristics were not associated with SDM. Those with difficulty contacting their clinician by telephone were 26% (ADHD: 55 vs 81%) and 29% (asthma: 48 vs 77%) less likely to have high SDM than those without difficulty. CONCLUSIONS: These findings indicate that households of children who report greater impairment or difficulty contacting their clinician by telephone are less likely to fully participate in SDM. Future research should examine how strategies to foster ongoing communication between families and clinicians affect SDM.

Primary Care Providers' Knowledge, Practices, and Perceived Barriers to the Treatment and Prevention of Childhood Obesity

This study evaluated primary care providers (PCPs, pediatricians, and nurse practitioners) knowledge, current practices, and perceived barriers to childhood obesity prevention and treatment, with an emphasis on first‐year well‐child care visits. A questionnaire was distributed to 192 PCPs in the primary care network at The Childrens Hospital of Philadelphia (CHOP) addressing (i) knowledge of obesity and American Academy of Pediatrics (AAP) guidelines, (ii) anticipatory guidance practices at well visits regarding nutrition and exercise, and (iii) perceived barriers to childhood obesity treatment and prevention. Eighty pediatricians and seven nurse practitioners responded, and a minority correctly identified the definition (26%) and prevalence (9%) of childhood overweight and AAP guidelines for exercise (39%) and juice consumption (44%). Most PCPs (81%) spent 11–20 min per well visit during the first 2 years, and 79% discussed diet, nutrition, and exercise for ≥3 min. Although >95% of PCPs discussed juice, fruits and vegetables, sippy cups, and finger foods during the first year, over 35% never discussed fast food, TV, or candy, and 55% never discussed exercise. Few rated current resources as adequate to treat or prevent childhood obesity. Over 90% rated the following barriers for obesity prevention and treatment as important or very important: parent is not motivated, child is not motivated, parents are overweight, families often have fast food, watch too much TV, and do not get enough exercise. In conclusion, there is much room to improve PCPs knowledge of obesity and AAP guidelines. Although PCPs rate fast‐food consumption, TV viewing, and lack of exercise as important treatment barriers, many never discussed these topics during the first year.

Placement Changes and Emergency Department Visits in the First Year of Foster Care

Objectives. Despite great needs, many children in foster care do not receive adequate medical care. Suboptimal care may be attributable in part to placement changes, which disrupt continuity of care by both a consistent surrogate parent and potentially a primary care physician. These disruptions in turn may lead to increased use of the emergency department (ED) for outpatient care. The primary aim of this study was to test whether a greater rate of placement changes was associated with increasing use of the ED among children in their first year of foster care. The secondary aim was to compare ED visit rates with rates of visits to other ambulatory care settings among children in foster care and other Medicaid-eligible children not in foster care. Methods. Using Medicaid claims linked to foster care administrative data, we assembled a retrospective cohort of foster children in a large urban municipality from 1993 to 1996. Eligible children spent at least 9 months in a new episode of foster care and were continuously eligible for Medicaid during a 1-year follow-up period. A comparison cohort was drawn from Medicaid-eligible children not in foster care during fiscal year 1995. The dependent variable was the rate of visits to the ED or other ambulatory care settings during a 1-year follow-up period. A negative binomial model estimated visit rates to the ED and other ambulatory care settings as the number of foster care placements increased. Potential interactions were considered between age and location of service use (ED or ambulatory care setting), between age and foster care placements, and between location of service use and number of foster care placements. Results. The 2358 children in the sample accounted for 1206 ED visits during the follow-up period; 38% experienced ≥2 placement changes. Children of all ages exhibited increasing reliance on the ED for ambulatory care services as the number of placements increased, with the rates of ED use more than doubling for all age groups beyond infancy. However, other ambulatory care service use increased by only 41% to 53%; there was much less utilization in these nonemergency settings for all children but particularly toddlers and infants, compared with their Medicaid-eligible peers. Although the absolute rates of all visits for younger foster children (<6 years of age) were low, older foster children had increasingly greater ED use than did their Medicaid-eligible peers, with nearly double the rate of ED visits in the adolescent age group. A temporal relationship between placements and ED visits was also identified; 75% of ED visits occurring within 3 weeks of a placement change occurred in the period after a placement change. Conclusions. Foster children received fewer overall outpatient services than did their Medicaid-eligible peers, but with age and increasing numbers of placements, had higher visit rates and received a greater proportion of their overall outpatient care in the ED. These results suggest that poor access to nonemergent ambulatory care settings might have contributed to an increasing reliance on ED settings as foster care placements increased. The temporal relationship between ED visits and placement changes underscores the need for better health care management for foster children, particularly in the period after placement changes.

One-Year Respiratory Outcomes of Preterm Infants Enrolled in the Nitric Oxide (to Prevent) Chronic Lung Disease Trial

OBJECTIVEnTo identify whether inhaled nitric oxide treatment decreased indicators of long-term pulmonary morbidities after discharge from the neonatal intensive care unit.nnnSTUDY DESIGNnThe Nitric Oxide (to Prevent) Chronic Lung Disease trial enrolled preterm infants (<1250 g) between 7 to 21 days of age who were ventilated and at high risk for bronchopulmonary dysplasia. Follow-up occurred at 12 +/- 3 months of age adjusted for prematurity; long-term pulmonary morbidity and other outcomes were reported by parents during structured blinded interviews.nnnRESULTSnA total of 456 infants (85%) were seen at 1 year. Compared with control infants, infants randomized to inhaled nitric oxide received significantly less bronchodilators (odds ratio [OR] 0.53 [95% confidence interval 0.36-0.78]), inhaled steroids (OR 0.50 [0.32-0.77]), systemic steroids (OR 0.56 [0.32-0.97]), diuretics (OR 0.54 [0.34-0.85]), and supplemental oxygen (OR 0.65 [0.44-0.95]) after discharge from the neonatal intensive care unit. There were no significant differences between parental report of rehospitalizations (OR 0.83 [0.57-1.21]) or wheezing or whistling in the chest (OR 0.70 [0.48-1.03]).nnnCONCLUSIONSnInfants treated with inhaled nitric oxide received fewer outpatient respiratory medications than the control group. However, any decision to institute routine use of this dosing regimen should also take into account the results of the 24-month neurodevelopmental assessment.

Patterns of health care use that may identify young children who are at risk for maltreatment

Objectives. Early identification of children who are at risk for maltreatment continues to pose a challenge to the medical community. The objective of this study was to determine whether children who are at risk for maltreatment have characteristic patterns of health care use before their diagnosis of abuse or neglect that distinguish them from other children. Methods. We performed a case-control study among Medicaid-enrolled children to compare patterns of health service among maltreated children in the year before a first report for abuse or neglect that led to an immediate placement into foster care, with patterns of health service use among matched control subjects. Exposure variables, obtained from Medicaid claims, included the total number of non–emergency department (ED) outpatient visits, the total number of ED visits, the frequency of injury-related diagnoses, the frequency of nonspecific diagnoses that have been previously linked to abuse, and the number of changes in a child’s primary care provider. Multivariate models were performed adjusting for cash assistance eligibility, race, and child comorbidities. Results. We characterized the health service use patterns, during the year before their first maltreatment report, of 157 children with serious and substantiated abuse or neglect. Health service use during the same period was also characterized among 628 control subjects who were matched by age, gender, and number of months of Medicaid eligibility. Sixteen percent of cases changed their primary care providers, compared with 10% of the control subjects. Multivariable modeling demonstrated that maltreated children were 2.62 (95% confidence interval: 1.40–4.91) times more likely than control subjects to have had 1 previous change in primary care provider and 6.87 (95% confidence interval: 1.96–24.16) times more likely to have changed providers 2 or more times during the year before their first maltreatment report. There were no differences between case patients and control subjects in the frequency of ED visits and rates of diagnoses of injury or nonspecific somatic complaints. Conclusions. Victims of serious and substantiated physical abuse and neglect change ambulatory care providers with greater frequency than nonabused children. Recognition of this patient characteristic may allow for earlier identification of children who are at risk for additional or future maltreatment.

A New Diagnosis Grouping System for Child Emergency Department Visits

OBJECTIVESnA clinically sensible system of grouping diseases is needed for describing pediatric emergency diagnoses for research and reporting. This project aimed to create an International Classification of Diseases (ICD)-based diagnosis grouping system (DGS) for child emergency department (ED) visits that is 1) clinically sensible with regard to how diagnoses are grouped and 2) comprehensive in accounting for nearly all diagnoses (>95%). The second objective was to assess the construct validity of the DGS by examining variation in the frequency of targeted groups of diagnoses within the concepts of season, age, sex, and hospital type.nnnMETHODSnA panel of general and pediatric emergency physicians used the nominal group technique and Delphi surveys to create the DGS. The primary data source used to develop the DGS was the Pediatric Emergency Care Applied Research Network (PECARN) Core Data Project (PCDP).nnnRESULTSnA total of 3,041 ICD-9 codes, accounting for 98.9% of all diagnoses in the PCDP, served as the basis for creation of the DGS. The expert panel developed a DGS framework representing a clinical approach to the diagnosis and treatment of pediatric emergency patients. The resulting DGS has 21 major groups and 77 subgroups and accounts for 96.5% to 99% of diagnoses when applied to three external data sets. Variations in the frequency of targeted groups of diagnoses related to seasonality, age, sex, and site of care confirm construct validity.nnnCONCLUSIONSnThe DGS offers a clinically sensible method for describing pediatric ED visits by grouping ICD-9 codes in a consensus-derived classification scheme. This system may be used for research, reporting, needs assessment, and resource planning.