Mark Ramos

Prevalence of Diagnosed Sleep Disorders in Pediatric Primary Care Practices

OBJECTIVES: The primary aim was to determine the prevalence of International Classification of Diseases, Ninth Revision (ICD-9), sleep disorders diagnosed by pediatric providers in a large, primary care network. Secondary aims were to examine demographic variables related to these diagnoses and to examine the frequency of prescriptions for medications potentially used to treat sleep disorders. METHODS: Electronic medical records were reviewed for 154957 patients (0–18 years) seen for a well-child visit in 2007. Information collected included ICD-9 sleep diagnoses, demographic variables, comorbid attention-deficit/hyperactivity disorder and autism spectrum disorders, provider type, and medications. RESULTS: Across all ages, 3.7% of youths had an ICD-9 diagnosis for a sleep disorder. The most-common diagnoses were sleep disorder not otherwise specified, enuresis, and sleep-disordered breathing. Predictors of sleep disorders varied according to developmental age group and included growth parameters, comorbid attention-deficit/hyperactivity disorder or autism spectrum disorder, and provider type. Potential sleep-related medications were prescribed for 6.1% of the sample subjects. CONCLUSIONS: This study is one of the first to examine comprehensively ICD-9 sleep diagnoses given by primary care providers in a large representative sample of children 0 to 18 years of age. The 3.7% of patients with ICD-9 sleep diagnoses is significantly lower than prevalence rates reported in epidemiological studies, which suggests that primary care providers may be underdiagnosing sleep disorders in children and adolescents. Because sleep disorders are treatable when recognized, the results from this study suggest a significant need for additional education and support for primary care providers in the diagnosis and treatment of pediatric sleep disorders.

Health Care Worker Exposures to Pertussis: Missed Opportunities for Prevention

OBJECTIVE: Pediatric health care workers (HCWs) are at particular risk for pertussis exposure, infection, and subsequent disease transmission to susceptible patients. This cross-sectional study describes the epidemiology of occupational exposures to pertussis and identifies factors that may inform interventions to promote effective implementation of infection prevention and control (IPC) guidelines. METHODS: We abstracted data from occupational health (OH) and IPC records for pertussis cases that resulted in an exposure investigation in a large quaternary pediatric care network, January 1, 2002 to July 18, 2011. We calculated the frequency of occupational exposures and measured associated characteristics. To assess the frequency of potential missed exposures, we reviewed electronic health record (EHR) data identifying laboratory-confirmed pertussis cases not documented in OH or IPC records. RESULTS: A total of 1193 confirmed HCW pertussis exposures were associated with 219 index cases during the study period. Of these, 38.8% were infants <6 months old and 7 were HCWs. Most (77.5%) of exposures occurred in the emergency department or an ambulatory site; 27.0% of exposures occurred after documented initiation of IPC precautions. We identified 450 laboratory-confirmed pertussis cases through EHR review, of which 49.8% (N = 224) had no OH or IPC investigation. The majority of uninvestigated cases (77.2%) were from ambulatory sites. CONCLUSIONS: Occupational exposures to pertussis occur frequently in pediatric health care settings despite appropriate IPC guidelines. Interventions are needed to ensure consistent implementation of IPC practices and timely identification and reporting of pertussis index cases to prevent HCW exposures and potential transmission to patients.

Medically Underserved Girls Receive Less Evaluation for Short Stature

OBJECTIVE: To determine if gender is associated with diagnostic evaluation by primary care pediatricians caring for children with growth-faltering. PATIENTS AND METHODS: This was a retrospective study of children who were attending 4 urban pediatric primary care practices affiliated with a tertiary pediatric hospital. Growth-faltering was defined as height at the <5th percentile or a z-score decrease of ≥1.5 SDs before 18 months of age or ≥1 SD thereafter. For each child, height z score, age, gender, race, insurance, diagnostic tests, and subspecialist appointments were examined. RESULTS: Of 33 476 children, 3007 had growth-faltering (mean height: −1.5 ± 1.0 vs 0.3 ± 0.9 SDs in those without growth-faltering). Boys comprised 53% of the growth-faltering group (vs 51% of the nonfaltering group; P < .01). Among children with growth-faltering, 2.8% had endocrinology appointments (vs 0.8% of others; P < .0001) and 6% had gastroenterology appointments (vs 1.5% of others; P < .0001). Subspecialty care was not associated with gender. Pediatricians ordered diagnostic tests for a significantly greater proportion of children with growth-faltering than others. In multivariate analysis of height z score among children with growth-faltering, tests for chromosomes (1.4% of short girls vs 0.4% of short boys; P < .005) and growth hormone/insulin-like growth factor axis (0.9% of short girls vs 1.8% of short boys; P < .05) were associated with gender. Thirty-five percent of the girls for whom chromosome testing was performed were 12 years old or older. CONCLUSIONS: Patterns in diagnostic testing of children with growth-faltering by their pediatricians may lead to underdiagnosis of Turner syndrome and growth hormone deficiency among girls.

Gender Bias in U.S. Pediatric Growth Hormone Treatment

Growth hormone (GH) treatment of idiopathic short stature (ISS), defined as height <−2.25 standard deviations (SD), is approved by U.S. FDA. This study determined the gender-specific prevalence of height <−2.25 SD in a pediatric primary care population, and compared it to demographics of U.S. pediatric GH recipients. Data were extracted from health records of all patients age 0.5–20 years with ≥ 1 recorded height measurement in 28 regional primary care practices and from the four U.S. GH registries. Height <−2.25 SD was modeled by multivariable logistic regression against gender and other characteristics. Of the 189,280 subjects, 2073 (1.1%) had height <−2.25 SD. No gender differences in prevalence of height <−2.25 SD or distribution of height Z-scores were found. In contrast, males comprised 74% of GH recipients for ISS and 66% for all indications. Short stature was associated (Pu2009<u20090.0001) with history of prematurity, race/ethnicity, age and Medicaid insurance, and inversely related (Pu2009<u20090.0001) with BMI Z-score. In conclusion, males outnumbered females almost 3:1 for ISS and 2:1 for all indications in U.S. pediatric GH registries despite no gender difference in height <−2.25 SD in a large primary care population. Treatment and/or referral bias was the likely cause of male predominance among GH recipients.

Clinical Decision Support and Palivizumab: A Means to Protect from Respiratory Syncytial Virus.

BACKGROUND AND OBJECTIVESnPalivizumab can reduce hospitalizations due to respiratory syncytial virus (RSV), but many eligible infants fail to receive the full 5-dose series. The efficacy of clinical decision support (CDS) in fostering palivizumab receipt has not been studied. We sought a comprehensive solution for identifying eligible patients and addressing barriers to palivizumab administration.nnnMETHODSnWe developed workflow and CDS tools targeting patient identification and palivizumab administration. We randomized 10 practices to receive palivizumab-focused CDS and 10 to receive comprehensive CDS for premature infants in a 3-year longitudinal cluster-randomized trial with 2 baseline and 1 intervention RSV seasons.nnnRESULTSnThere were 356 children eligible to receive palivizumab, with 194 in the palivizumab-focused group and 162 in the comprehensive CDS group. The proportion of doses administered to children in the palivizumab-focused intervention group increased from 68.4% and 65.5% in the two baseline seasons to 84.7% in the intervention season. In the comprehensive intervention group, proportions of doses administered declined during the baseline seasons (from 71.9% to 62.4%) with partial recovery to 67.9% during the intervention season. The palivizumab-focused group improved by 19.2 percentage points in the intervention season compared to the prior baseline season (p < 0.001), while the comprehensive intervention group only improved 5.5 percentage points (p = 0.288). The difference in change between study groups was significant (p = 0.05).nnnCONCLUSIONSnWorkflow and CDS tools integrated in an EHR may increase the administration of palivizumab. The support focused on palivizumab, rather than comprehensive intervention, was more effective at improving palivizumab administration.

Eosinophilic Esophagitis is a Late Manifestation of the Atopic March

BACKGROUNDnThe allergic march describes the natural history of allergic conditions as they develop during childhood. Eosinophilic esophagitis (EoE) is a chronic allergic inflammatory disease that can be triggered by specific foods. Despite its allergic pathophysiology, the epidemiologic relationship between EoE and established members of the allergic march is unknown.nnnOBJECTIVEnWe sought to determine whether EoE meets epidemiologic criteria for being considered a member of the allergic march.nnnMETHODSnUsing a primary care birth cohort of 130,435 children, we determined the natural histories of atopic dermatitis (AD), IgE-mediated food allergy (IgE-FA), asthma, EoE, and allergic rhinitis (AR) in individual patients. We then performed case-control analyses to establish the extent that existing allergic conditions influence the rate of subsequent EoE diagnosis.nnnRESULTSnA total of 139 children developed EoE during the observation period (prevalence of 0.11%). The peak age of EoE diagnosis was 2.6 years, as compared with 0.3 years, 1 year, 1.1 years, and 2.1 years for AD, IgE-FA, asthma, and AR, respectively. The presence of AD (hazard ratio [HR] 3.2, 95% confidence interval [CI] 2.2-4.6), IgE-FA (HR 9.1, 95% CI 6.5-12.6), and asthma (HR 1.9, 95% CI 1.3-2.7) was independently and cumulatively associated with subsequent EoE diagnosis. The presence of AR was associated with subsequent EoE diagnosis (HR 2.8, 95% CI 2.0-3.9), and the presence of EoE was associated with subsequent AR diagnosis (HR 2.5, 95% CI 1.7-3.5).nnnCONCLUSIONSnAllergic comorbidities are positively associated with EoE diagnosis. Together, our findings suggest that EoE is a late manifestation of the allergic march.

Pediatric asthma hospitalizations among urban minority children and the continuity of primary care

ABSTRACT Objective: To examine the effect of ambulatory health care processes on asthma hospitalizations. Methods: A retrospective cohort study using electronic health records was completed. Patients aged 2–18 years receiving health care from 1 of 5 urban practices between Jan 1, 2004 and Dec 31, 2008 with asthma documented on their problem list were included. Independent variables were modifiable health care processes in the primary care setting: (1) use of asthma controller medications; (2) regular assessment of asthma symptoms; (3) use of spirometry; (4) provision of individualized asthma care plans; (5) timely influenza vaccination; (6) access to primary healthcare; and (7) use of pay for performance physician incentives. Occurrence of one or more asthma hospitalizations was the primary outcome of interest. We used a log linear model (Poisson regression) to model the association between the factors of interest and number of asthma hospitalizations. Results: 5,712 children with asthma were available for analysis. 96% of the children were African American. The overall hospitalization rate was 64 per 1,000 children per year. None of the commonly used asthma-specific indicators of high quality care were associated with fewer asthma hospitalizations. Children with documented asthma who experienced a lack of primary health care (no more than one outpatient visit at their primary care location in the 2 years preceding hospitalization) were at higher risk of hospitalization compared to those children with a greater number of visits (incidence rate ratio 1.39; 95% CI 1.09–1.78). Conclusions: In children with asthma, more frequent primary care visits are associated with reduced asthma hospitalizations.

Identifying surgical site infections in electronic health data using predictive models

ObjectivenThe objective was to prospectively derive and validate a prediction rule for detecting cases warranting investigation for surgical site infections (SSI) after ambulatory surgery.nnnMethodsnWe analysed electronic health record (EHR) data for children who underwent ambulatory surgery at one of 4 ambulatory surgical facilities. Using regularized logistic regression and random forests, we derived SSI prediction rules using 30 months of data (derivation set) and evaluated performance with data from the subsequent 10 months (validation set). Models were developed both with and without data extracted from free text. We also evaluated the presence of an antibiotic prescription within 60 days after surgery as an independent indicator of SSI evidence. Our goal was to exceed 80% sensitivity and 10% positive predictive value (PPV).nnnResultsnWe identified 234 surgeries with evidence of SSI among the 7910 surgeries available for analysis. We derived and validated an optimal prediction rule that included free text data using a random forest model (sensitivityu2009=u20090.9, PPVu2009=u20090.28). Presence of an antibiotic prescription had poor sensitivity (0.65) when applied to the derivation data but performed better when applied to the validation data (sensitivityu2009=u20090.84, PPVu2009=u20090.28).nnnConclusionsnEHR data can facilitate SSI surveillance with adequate sensitivity and PPV.

User Testing an Information Foraging Tool for Ambulatory Surgical Site Infection Surveillance

BACKGROUNDnSurveillance for surgical site infections (SSIs) after ambulatory surgery in children requires a detailed manual chart review to assess criteria defined by the National Health and Safety Network (NHSN). Electronic health records (EHRs) impose an inefficient search process where infection preventionists must manually review every postsurgical encounter (< 30 days). Using text mining and business intelligence software, we developed an information foraging application, the SSI Workbench, to visually present which postsurgical encounters included SSI-related terms and synonyms, antibiotic, and culture orders.nnnOBJECTIVEnThis article compares the Workbench and EHR on four dimensions: (1) effectiveness, (2) efficiency, (3) workload, and (4) usability.nnnMETHODSnComparative usability test of Workbench and EHR. Objective test metrics are time per case, encounters reviewed per case, time per encounter, and retrieval of information meeting NHSN definitions. Subjective measures are cognitive load using the National Aeronautics and Space Administration (NASA) Task Load Index (NASA TLX), and a questionnaire on system usability and utility.nnnRESULTSnEight infection preventionists participated in the test. There was no difference in effectiveness as subjects retrieved information from all cases, using both systems, to meet the NHSN criteria. There was no difference in efficiency in time per case between the Workbench and EHR (8.58 vs. 7.39 minutes, pu2009=u20090.36). However, with the Workbench subjects opened fewer encounters per case (3.0 vs. 7.5, pu2009=u20090.002), spent more time per encounter (2.23 vs. 0.92 minutes, pu2009=u20090.002), rated the Workbench lower in cognitive load (NASA TLX, 24 vs. 33, pu2009=u20090.02), and significantly higher in measures of usability.nnnCONCLUSIONnCompared with the EHR, the Workbench was more usable, short, and reduced cognitive load. In overall efficiency, the Workbench did not save time, but demonstrated a shift from between-encounter foraging to within-encounter foraging and was rated as significantly more efficient. Our results suggest that infection surveillance can be better supported by systems applying information foraging theory.

Rapid Adjustment of Clinical Decision Support in Response to Updated Recommendations for Palivizumab Eligibility

Background: Palivizumab is effective at reducing hospitalizations due to respiratory syncytial virus among high-risk children, but is indicated for a small population. Identification of patients eligible to receive palivizumab is labor-intensive and error-prone. To support patient identification we developed Clinical Decision Support (CDS) based on published recommendations in 2012. This CDS was developed using a systematic process, which directly linked computer code to a recommendation’s narrative text. In 2014, updated recommendations were published, which changed several key criteria used to determine eligible patients. Objective: Assess the effort required to update CDS in response to new palivizumab recommendations and identify factors that impacted these efforts. Methods: We reviewed the updated American Academy of Pediatrics (AAP) policy statement from Aug 2014 and identified areas of divergence from the prior publication. We modified the CDS to account for each difference. We recorded time spent on each activity to approximate the total effort required to update the CDS. Results: Of the 15 recommendations in the initial policy statement, 7 required updating. The CDS update was completed in 11 person-hours. Comparison of old and new recommendations was facilitated by the AAP policy statement structure and required 3 hours. Validation of the revised logic required 2 hours by a clinical domain expert. An informaticist required 3 hours to update and test the CDS. This included adding 24 lines and deleting 37 lines of code. Updating relevant data queries took an additional 3 hours and involved 10 edits. Conclusion: We quickly adapted CDS in response to changes in recommendations for palivizumab administration. The consistent AAP policy statement structure and the link we developed between these statements and the CDS rules facilitated our efforts. We recommend that CDS implementers establish linkages between published narrative recommendations and their executable rules to facilitate maintenance efforts.