Lihai Song

Effectiveness of Decision Support for Families, Clinicians, or Both on HPV Vaccine Receipt

OBJECTIVE: To improve human papillomavirus (HPV) vaccination rates, we studied the effectiveness of targeting automated decision support to families, clinicians, or both. METHODS: Twenty-two primary care practices were cluster-randomized to receive a 3-part clinician-focused intervention (education, electronic health record-based alerts, and audit and feedback) or none. Overall, 22 486 girls aged 11 to 17 years due for HPV vaccine dose 1, 2, or 3 were randomly assigned within each practice to receive family-focused decision support with educational telephone calls. Randomization established 4 groups: family-focused, clinician-focused, combined, and no intervention. We measured decision support effectiveness by final vaccination rates and time to vaccine receipt, standardized for covariates and limited to those having received the previous dose for HPV #2 and 3. The 1-year study began in May 2010. RESULTS: Final vaccination rates for HPV #1, 2, and 3 were 16%, 65%, and 63% among controls. The combined intervention increased vaccination rates by 9, 8, and 13 percentage points, respectively. The control group achieved 15% vaccination for HPV #1 and 50% vaccination for HPV #2 and 3 after 318, 178, and 215 days. The combined intervention significantly accelerated vaccination by 151, 68, and 93 days. The clinician-focused intervention was more effective than the family-focused intervention for HPV #1, but less effective for HPV #2 and 3. CONCLUSIONS: A clinician-focused intervention was most effective for initiating the HPV vaccination series, whereas a family-focused intervention promoted completion. Decision support directed at both clinicians and families most effectively promotes HPV vaccine series receipt.

Variation in Quality of Tonsillectomy Perioperative Care and Revisit Rates in Children’s Hospitals

OBJECTIVE: To describe the quality of care for routine tonsillectomy at US children’s hospitals. METHODS: We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children’s hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital. RESULTS: Of 139 715 children who underwent same-day tonsillectomy, 10 868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%–98.8%) and antibiotics (median 16.3%, range 2.7%–92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10–18 vs 1–3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P < .001) across hospitals in total revisits (median 7.8%, range 3.0%–12.6%), revisits for bleeding (median 3.0%, range 1.0%–8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%–4.4%). CONCLUSIONS: Substantial variation exists in the quality of care for routine tonsillectomy across US children’s hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals’ tonsillectomy quality improvement efforts.

Annual Incidence of Nephrolithiasis among Children and Adults in South Carolina from 1997 to 2012

BACKGROUND AND OBJECTIVES The prevalence of nephrolithiasis in the United States has increased substantially, but recent changes in incidence with respect to age, sex, and race are not well characterized. This study examined temporal trends in the annual incidence and cumulative risk of nephrolithiasis among children and adults living in South Carolina over a 16-year period. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS We performed a population-based, repeated cross-sectional study using the US Census and South Carolina Medical Encounter data, which capture all emergency department visits, surgeries, and admissions in the state. The annual incidence of nephrolithiasis in South Carolina from 1997 to 2012 was estimated, and linear mixed models were used to estimate incidence rate ratios for age, sex, and racial groups. The cumulative risk of nephrolithiasis during childhood and over the lifetime was estimated for males and females in 1997 and 2012. RESULTS Among an at-risk population of 4,625,364 people, 152,925 unique patients received emergency, inpatient, or surgical care for nephrolithiasis. Between 1997 and 2012, the mean annual incidence of nephrolithiasis increased 1% annually from 206 to 239 per 100,000 persons. Among age groups, the greatest increase was observed among 15-19 year olds, in whom incidence increased 26% per 5 years (incidence rate ratio, 1.26; 95% confidence interval, 1.22 to 1.29). Adjusting for age and race, incidence increased 15% per 5 years among females (incidence rate ratio, 1.15; 95% confidence interval, 1.14 to 1.16) but remained stable for males. The incidence among blacks increased 15% more per 5 years compared with whites (incidence rate ratio, 1.15; 95% confidence interval, 1.14 to 1.17). These changes in incidence resulted in doubling of the risk of nephrolithiasis during childhood and a 45% increase in the lifetime risk of nephrolithiasis for women over the study period. CONCLUSIONS The incidence of kidney stones has increased among young patients, particularly women, and blacks.

Cost-Benefit Analysis of a Medical Emergency Team in a Children’s Hospital

OBJECTIVES: Medical emergency teams (METs) can reduce adverse events in hospitalized children. We aimed to model the financial costs and benefits of operating an MET and determine the annual reduction in critical deterioration (CD) events required to offset MET costs. METHODS: We performed a single-center cohort study between July 1, 2007 and March 31, 2012 to determine the cost of CD events (unplanned transfers to the ICU with mechanical ventilation or vasopressors in the 12 hours after transfer) as compared with transfers to the ICU without CD. We then performed a cost-benefit analysis evaluating varying MET compositions and staffing models (freestanding or concurrent responsibilities) on the annual reduction in CD events needed to offset MET costs. RESULTS: Patients who had CD cost

Association of Bystander Cardiopulmonary Resuscitation With Overall and Neurologically Favorable Survival After Pediatric Out-of-Hospital Cardiac Arrest in the United States: A Report From the Cardiac Arrest Registry to Enhance Survival Surveillance Registry

99 773 (95% confidence interval,

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

69 431 to

Evaluation for Occult Fractures in Injured Children

130 116; P < .001) more during their post-event hospital stay than transfers to the ICU that did not meet CD criteria. Annual MET operating costs ranged from

Dexamethasone and Risk of Bleeding in Children Undergoing Tonsillectomy

287 145 for a nurse and respiratory therapist team with concurrent responsibilities to

Variations in Mental Health Diagnosis and Prescribing Across Pediatric Primary Care Practices

2 358 112 for a nurse, respiratory therapist, and ICU attending physician freestanding team. In base-case analysis, a nurse, respiratory therapist, and ICU fellow team with concurrent responsibilities cost

Changing Patterns of Alpha Agonist Medication Use in Children and Adolescents 2009–2011

350 698 per year, equivalent to a reduction of 3.5 CD events. CONCLUSIONS: CD is expensive. The costs of operating a MET can plausibly be recouped with a modest reduction in CD events. Hospitals reimbursed with bundled payments could achieve real financial savings by reducing CD with an MET.