Mark W. Shen

Choosing wisely in pediatric hospital medicine: Five opportunities for improved healthcare value

BACKGROUND Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under-recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric work groups results. METHODS A work group of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care.

Decreasing unnecessary utilization in acute bronchiolitis care: Results from the value in inpatient pediatrics network

BACKGROUND Acute viral bronchiolitis is the most common diagnosis resulting in hospital admission in pediatrics. Utilization of non-evidence-based therapies and testing remains common despite a large volume of evidence to guide quality improvement efforts. OBJECTIVE Our objective was to reduce utilization of unnecessary therapies in the inpatient care of bronchiolitis across a diverse network of clinical sites. METHODS We formed a voluntary quality improvement collaborative of pediatric hospitalists for the purpose of benchmarking the use of bronchodilators, steroids, chest radiography, chest physiotherapy, and viral testing in bronchiolitis using hospital administrative data. We shared resources within the network, including protocols, scores, order sets, and key bibliographies, and established group norms for decreasing utilization. RESULTS Aggregate data on 11,568 hospitalizations for bronchiolitis from 17 centers was analyzed for this report. The network was organized in 2008. By 2010, we saw a 46% reduction in overall volume of bronchodilators used, a 3.4 dose per patient absolute decrease in utilization (95% confidence interval [CI] 1.4-5.8). Overall exposure to any dose of bronchodilator decreased by 12 percentage points as well (95% CI 5%-25%). There was also a statistically significant decline in chest physiotherapy usage, but not for steroids, chest radiography, or viral testing. CONCLUSIONS Benchmarking within a voluntary pediatric hospitalist collaborative facilitated decreased utilization of bronchodilators and chest physiotherapy in bronchiolitis.

Diagnostic and Therapeutic Challenges of Childhood Brucellosis in a Nonendemic Country

OBJECTIVE. We sought to define the current epidemiology, clinical manifestations, and course of childhood brucellosis in the United States. METHODS. A retrospective chart review was performed of 20 patients who received a diagnosis of brucellosis over a period of 13 years at a large, tertiary care childrens hospital in Dallas, Texas. Diagnostic criteria, epidemiology, clinical presentations, and outcomes were recorded. RESULTS. Ninety-five percent of the patients had a recent history of either travel to Mexico or ingestion of unpasteurized milk products from Mexico. Fever was an initial complaint in 80% of the patients, and 50% of the patients presented with arthritis. Diagnosis was made via the identification of Brucella melitensis in the blood cultures of 18 patients. Five patients experienced relapse, and 3 experienced treatment failure. CONCLUSIONS. Childhood brucellosis in the United States is now an imported disease, primarily from Mexico. In the context of this epidemiologic link, the diagnosis should be entertained for a patient who presents with signs of systemic inflammation and arthritis. Therapeutic challenges remain.

Diagnostic Accuracy of the Urinalysis for Urinary Tract Infection in Infants <3 Months of Age

BACKGROUND: The 2011 American Academy of Pediatrics urinary tract infection (UTI) guideline suggests incorporation of a positive urinalysis (UA) into the definition of UTI. However, concerns linger over UA sensitivity in young infants. Infants with the same pathogenic organism in the blood and urine (bacteremic UTI) have true infections and represent a desirable population for examination of UA sensitivity. METHODS: We collected UA results on a cross-sectional sample of 276 infants <3 months of age with bacteremic UTI from 11 hospital systems. Sensitivity was calculated on infants who had at least a partial UA performed and had ≥50 000 colony-forming units per milliliter from the urine culture. Specificity was determined by using a random sample of infants from the central study site with negative urine cultures. RESULTS: The final sample included 245 infants with bacteremic UTI and 115 infants with negative urine cultures. The sensitivity of leukocyte esterase was 97.6% (95% confidence interval [CI] 94.5%–99.2%) and of pyuria (>3 white blood cells/high-power field) was 96% (95% CI 92.5%–98.1%). Only 1 infant with bacteremic UTI (Group B Streptococcus) and a complete UA had an entirely negative UA. In infants with negative urine cultures, leukocyte esterase specificity was 93.9% (95% CI 87.9 – 97.5) and of pyuria was 91.3% (84.6%–95.6%). CONCLUSIONS: In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies.

Summary of STARNet: Seamless Transitions and (Re)admissions Network

The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics’ Quality Improvement Innovation Networks and the Section on Hospital Medicine.

Pediatric discharge content: a multisite assessment of physician preferences and experiences.

BACKGROUND AND OBJECTIVES Professional medical societies endorse prompt, consistent discharge communication to primary care providers (PCPs) on discharge. However, evidence is limited about what clinical elements to communicate. Our main goal was to identify and compare the clinical elements considered by PCPs and pediatric hospitalists to be essential to communicate to PCPs within 2 days of pediatric hospital discharge. A secondary goal was to describe experiences of the PCPs and pediatric hospitalists regarding sending and receiving discharge information. METHODS A survey of physician preferences and experiences regarding discharge communication was sent to 320 PCPs who refer patients to 16 hospitals, with an analogous survey sent to 147 hospitalists. Descriptive statistics were calculated, and χ² analyses were performed. RESULTS A total of 201 PCPs (63%) and 71 hospitalists (48%) responded to the survey. Seven clinical elements were reported as essential by >75% of both PCPs and hospitalists: dates of admission and discharge; discharge diagnoses; brief hospital course; discharge medications; immunizations given during hospitalization; pending laboratory or test results; and follow-up appointments. PCPs reported reliably receiving discharge communication significantly less often than hospitalists reported sending it (71.8% vs 85.1%; P < .01), and PCPs considered this communication to be complete significantly less often than hospitalists did (64.9% vs 79.1%; P < .01). CONCLUSIONS We identified 7 core clinical elements that PCPs and hospitalists consider essential in discharge communication. Consistently and promptly communicating at least these core elements after discharge may enhance PCP satisfaction and patient-level outcomes. Reported rates of transmission and receipt of this information were suboptimal and should be targeted for improvement.

Bacteraemic urinary tract infection: Management and outcomes in young infants

Objectives To determine predictors of parenteral antibiotic duration and the association between parenteral treatment duration and relapses in infants <3 months with bacteraemic urinary tract infection (UTI). Design Multicentre retrospective cohort study. Setting Eleven healthcare institutions across the USA. Patients Infants <3 months of age with bacteraemic UTI, defined as the same pathogenic organism isolated from blood and urine. Main outcome measures Duration of parenteral antibiotic therapy, relapsed UTI within 30 days. Results The mean (±SD) duration of parenteral antibiotics for the 251 included infants was 7.8 days (±4 days), with considerable variability between institutions (mean range 5.5–12 days). Independent predictors of the duration of parenteral antibiotic therapy included (coefficient, 95% CI): age (−0.2 days, −0.3 days to −0.08 days, for each week older), year treated (−0.2 days, −0.4 to −0.03 days for each subsequent calendar year), male gender (0.9 days, 0.01 to 1.8 days), a positive repeat blood culture during acute treatment (3.5 days, 1.2–5.9 days) and a non-Escherichia coli organism (2.2 days, 0.8–3.6 days). No infants had a relapsed bacteraemic UTI. Six infants (2.4%) had a relapsed UTI (without bacteraemia). The duration of parenteral antibiotics did not differ between infants with and without a relapse (8.2 vs 7.8 days, p=0.81). Conclusions Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

Quality improvement research in pediatric hospital medicine and the role of the Pediatric Research in Inpatient Settings (PRIS) network

Pediatric hospitalists care for many hospitalized children in community and academic settings, and they must partner with administrators, other inpatient care providers, and researchers to assure the reliable delivery of high-quality, safe, evidence-based, and cost-effective care within the complex inpatient setting. Paralleling the growth of the field of pediatric hospital medicine is the realization that innovations are needed to address some of the most common clinical questions. Some of the unique challenges facing pediatric hospitalists include the lack of evidence for treating common conditions, children with chronic complex conditions, compressed time frame for admissions, and the variety of settings in which hospitalists practice. Most pediatric hospitalists are engaged in some kind of quality improvement (QI) work as hospitals provide many opportunities for QI activity and innovation. There are multiple national efforts in the pediatric hospital medicine community to improve quality, including the Childrens Hospital Association (CHA) collaboratives and the Value in Pediatrics Network (VIP). Pediatric hospitalists are also challenged by the differences between QI and QI research; understanding that while improving local care is important, to provide consistent quality care to children we must study single-center and multicenter QI efforts by designing, developing, and evaluating interventions in a rigorous manner, and examine how systems variations impact implementation. The Pediatric Research in Inpatient Setting (PRIS) network is a leader in QI research and has several ongoing projects. The Prioritization project and Pediatric Health Information System Plus (PHIS+) have used administrative data to study variations in care, and the IIPE-PRIS Accelerating Safe Sign-outs (I-PASS) study highlights the potential for innovative QI research methods to improve care and clinical training. We address the importance, current state, accomplishments, and challenges of QI and QI research in pediatric hospital medicine; define the role of the PRIS Network in QI research; describe an exemplary QI research project, the I-PASS Study; address challenges for funding, training and mentorship, and publication; and identify future directions for QI research in pediatric hospital medicine.

Antibiotic and Diagnostic Discordance Between ED Physicians and Hospitalists for Pediatric Respiratory Illness.

BACKGROUND AND OBJECTIVE Imperfect diagnostic tools make it difficult to know the extent to which a bacterial process is contributing to respiratory illness, complicating the decision to prescribe antibiotics. We sought to quantify diagnostic and antibiotic prescribing disagreements between emergency department (ED) and pediatric hospitalist physicians for children admitted with respiratory illness. METHODS Manual chart review was used to identify testing, diagnostic, and antibiotic prescribing decisions for consecutive children admitted for respiratory illness in a winter (starting February 20, 2012) and a summer (starting August 20, 2012) season to a tertiary, freestanding childrens hospital. Respiratory illness diagnoses were grouped into 3 categories: bacterial, viral, and asthma. RESULTS A total of 181 children admitted for respiratory illness were studied. Diagnostic discordance was significant for all 3 types of respiratory illness but greatest for bacterial (P<.001). Antibiotic prescribing discordance was significant (P<.001), with pediatric hospitalists changing therapy for 93% of patients prescribed antibiotics in the ED, including stopping antibiotics altogether for 62% of patients. CONCLUSIONS Significant diagnostic and antibiotic discordance between ED and pediatric hospitalist physicians exists for children admitted to the hospital for respiratory illness.

Measuring Handoffs: Can We Improve the Transition of Hospitalized Children?

* Abbreviations: CHIPRA — : Children’s Health Insurance Program Reauthorization Act PQMP — : Pediatric Quality Measures Program In early 2009, the passage in Congress of the Children’s Health Insurance Program Reauthorization Act (CHIPRA) called for the establishment of Pediatric Quality Measures Program (PQMP). CHIPRA-PQMP funded 7 Centers of Excellence tasked with finding “solutions to some of the most pressing issues in child health quality measurement.”1 Patient handoffs, or transitions of care, was 1 of the areas identified by CHIPRA-PQMP as a “pressing issue” for measure development and validation. Care transitions have been previously defined as “a set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.”2 Although it has not been exhaustively studied and thus far mostly examined in adults, the most explored transition event is the inpatient to outpatient transition, where data suggest as many as 1 in 5 patients can suffer adverse events related to poor communication and ineffective handoffs.3 Seven years after the establishment of the CHIPRA-PQMP Centers of Excellence, we get a glimpse at some of the fruits of this effort. … Address correspondence to Ricardo A. Quinonez, MD, 6621 Fannin St, Houston, TX 77030. E-mail: quinonez{at}bcm.edu