Kavita Parikh

Bronchiolitis Management Before and After the AAP Guidelines

BACKGROUND AND OBJECTIVES: Evidence-based practice guidelines for bronchiolitis management published by the American Academy of Pediatrics in 2006 recommend supportive care with limited diagnostic testing and treatment. We sought to determine the impact of these guidelines on the treatment of hospitalized children. METHODS: We analyzed data on inpatients with bronchiolitis aged 1 to 24 months from the Pediatric Health Information System, an administrative billing database, from November 1, 2004 to March 31, 2012. We compared trends in use of diagnostic and treatment resources before and after the publication of the guidelines by using segmented time series. RESULTS: A total of 41 pediatric hospitals contributed data to yield 130 262 patients; 58% were male, and 59% were publicly insured. Median age was 4.0 months (interquartile range, 2–9). Unadjusted analysis showed improvement in utilization rates before and after guidelines for diagnostic tests and for medications; however, there was no decreased use of antibiotics. A segmented regression analysis also demonstrated differences in rates of change before and after guidelines, with significant improvement for chest radiography, steroids, and bronchodilators (P < .0001). CONCLUSIONS: In a nationally representative cohort of pediatric hospitals, publication of the 2006 American Academy of Pediatrics bronchiolitis guidelines was associated with significant reductions in the use of diagnostic and therapeutic resources.

Establishing Benchmarks for the Hospitalized Care of Children With Asthma, Bronchiolitis, and Pneumonia

BACKGROUND AND OBJECTIVES: Asthma, pneumonia, and bronchiolitis are the leading causes of admission for pediatric patients; however, the lack of accepted benchmarks is a barrier to quality improvement efforts. Using data from children hospitalized with asthma, bronchiolitis, or pneumonia, the goals of this study were to: (1) measure the 2012 performance of freestanding children’s hospitals using clinical quality indicators; and (2) construct achievable benchmarks of care (ABCs) for the clinical quality indicators. METHODS: This study was a cross-sectional trial using the Pediatric Health Information System database. Patient inclusions varied according to diagnosis: asthma (International Classification of Diseases, Ninth Revision, Clinical Modification [ICD-9-CM] codes 493.0–493.92) from 2 to 18 years of age; bronchiolitis (ICD-9-CM codes 466.11 and 466.19) from 2 months to 2 years of age; and pneumonia (ICD-9-CM codes 480–486, 487.0) from 2 months to 18 years of age. ABC methods use the best-performing hospitals that comprise at least 10% of the total population to compute the benchmark. RESULTS: Encounters from 42 hospitals included: asthma, 22 186; bronchiolitis, 14 882; and pneumonia, 12 983. Asthma ABCs include: chest radiograph utilization, 24.5%; antibiotic administration, 6.6%; and ipratropium bromide use >2 days, 0%. Bronchiolitis ABCs include: chest radiograph utilization, 32.4%; viral testing, 0.6%; antibiotic administration, 18.5%; bronchodilator use >2 days, 11.4%; and steroid use, 6.4%. Pneumonia ABCs include: complete blood cell count utilization, 28.8%; viral testing, 1.5%; initial narrow-spectrum antibiotic use, 60.7%; erythrocyte sedimentation rate, 3.5%; and C-reactive protein, 0.1%. CONCLUSIONS: We report achievable benchmarks for inpatient care for asthma, bronchiolitis, and pneumonia. The establishment of national benchmarks will drive improvement at individual hospitals.

Narrow Vs Broad-spectrum Antimicrobial Therapy for Children Hospitalized With Pneumonia

BACKGROUND: The 2011 Pediatric Infectious Diseases Society/Infectious Diseases Society of America community-acquired pneumonia (CAP) guideline recommends narrow-spectrum antimicrobial therapy for most children hospitalized with CAP. However, few studies have assessed the effectiveness of this strategy. METHODS: Using data from 43 children’s hospitals, we conducted a retrospective cohort study to compare outcomes and resource utilization among children hospitalized with CAP between 2005 and 2011 receiving either parenteral ampicillin/penicillin (narrow spectrum) or ceftriaxone/cefotaxime (broad spectrum). Children with complex chronic conditions, interhospital transfers, recent hospitalization, or the occurrence of any of the following during the first 2 calendar days of hospitalization were excluded: pleural drainage procedure, admission to intensive care, mechanical ventilation, death, or hospital discharge. RESULTS: Overall, 13 954 children received broad-spectrum therapy (89.7%) and 1610 received narrow-spectrum therapy (10.3%). The median length of stay was 3 days (interquartile range 3–4) in the broad- and narrow-spectrum therapy groups (adjusted difference 0.12 days, 95% confidence interval [CI]: –0.02 to 0.26). One hundred fifty-six children (1.1%) receiving broad-spectrum therapy and 13 children (0.8%) receiving narrow-spectrum therapy were admitted to intensive care (adjusted odds ratio 0.85, 95% CI: 0.27 to 2.73). Readmission occurred for 321 children (2.3%) receiving broad-spectrum therapy and 39 children (2.4%) receiving narrow-spectrum therapy (adjusted odds ratio 0.85, 95% CI: 0.45 to 1.63). Median costs for the hospitalization were

Influence of Hospital Guidelines on Management of Children Hospitalized With Pneumonia

3992 and

Readmissions among children previously hospitalized with pneumonia.

4375 (adjusted difference –

Industry relationships with pediatricians: Findings from the open payments sunshine act

14.4, 95% CI: –177.1 to 148.3). CONCLUSIONS: Clinical outcomes and costs for children hospitalized with CAP are not different when treatment is with narrow- compared with broad-spectrum therapy.

Impact of Inpatient Bronchiolitis Clinical Practice Guideline Implementation on Testing and Treatment

BACKGROUND AND OBJECTIVE: Clinical practice guidelines (CPGs) assist clinicians in making appropriate diagnostic and treatment decisions based on available evidence. The objective of this study was to describe the availability and content of institutional community-acquired pneumonia (CAP) CPGs, and to evaluate the association between institutional CPGs and care utilization, antibiotic administration, and outcomes among children hospitalized with CAP. METHODS: This multicenter retrospective cohort study included children aged 1 to 18 years hospitalized with CAP from July 1, 2009, to June 30, 2011. CPGs from each institution were reviewed to abstract information regarding diagnostic testing and antimicrobial selection. We compared overall and specific utilization patterns, antimicrobial use, and hospital length of stay (LOS) for children with CAP between hospitals with and without CPGs. RESULTS: Thirteen (31.7%) of 41 hospitals had an institutional CPG for nonsevere CAP. There was marked heterogeneity among CPGs. Among the 19 710 children hospitalized with CAP, cost of care, hospital LOS, and 14-day readmission rate were not associated with the presence of a CPG. CPGs did not influence ordering patterns for most diagnostic tests, including blood culture and chest radiographs. Penicillin or aminopenicillins were prescribed to 46.3% of children at institutions where a CPG recommended the use of these antibiotics as first-line agents compared with 23.9% of children at institutions without a CPG (odds ratio = 2.7; 95% confidence interval = 1.4–5.5). CONCLUSIONS: The availability of a CAP CPG had minimal impact on resource utilization and was not associated with cost or hospital LOS. Institutional CPGs, however, did influence patterns of antimicrobial use.

Comparative Effectiveness of Dexamethasone versus Prednisone in Children Hospitalized with Asthma

BACKGROUND AND OBJECTIVES: Pneumonia is a leading cause of hospitalization and readmission in children. Understanding the patient characteristics associated with pneumonia readmissions is necessary to inform interventions to reduce avoidable hospitalizations and related costs. The objective of this study was to characterize readmission rates, and identify factors and costs associated with readmission among children previously hospitalized with pneumonia. METHODS: Retrospective cohort study of children hospitalized with pneumonia at the 43 hospitals included in the Pediatric Health Information System between January 1, 2008, and December 31, 2011. The primary outcome was all-cause readmission within 30 days after hospital discharge, and the secondary outcome was pneumonia-specific readmission. We used multivariable regression models to identify patient and hospital characteristics and costs associated with readmission. RESULTS: A total of 82 566 children were hospitalized with pneumonia (median age, 3 years; interquartile range 1–7). Thirty-day all-cause and pneumonia-specific readmission rates were 7.7% and 3.1%, respectively. Readmission rates were higher among children <1 year of age, as well as in patients with previous hospitalizations, longer index hospitalizations, and complicated pneumonia. Children with chronic medical conditions were more likely to experience all-cause (odds ratio 3.0; 95% confidence interval 2.8–3.2) and pneumonia-specific readmission (odds ratio 1.8; 95% confidence interval 1.7–2.0) compared with children without chronic medical conditions. The median cost of a readmission (

Do we need this blood culture

11 344) was higher than that of an index admission (

A Multicenter Collaborative to Improve Care of Community Acquired Pneumonia in Hospitalized Children

4495; P = .01). Readmissions occurred in 8% of pneumonia hospitalizations but accounted for 16.3% of total costs for all pneumonia hospitalizations. CONCLUSIONS: Readmissions are common after hospitalization for pneumonia, especially among young children and those with chronic medical conditions, and are associated with substantial costs.