Matthew D. Garber

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.

A Multicenter Collaborative to Reduce Unnecessary Care in Inpatient Bronchiolitis

BACKGROUND AND OBJECTIVE: Evidence-based gGuidelines for acute viral bronchiolitis recommend primarily supportive care, but unnecessary care remains well documented. Published quality improvement work has been accomplished inchildren’s hospitals, but little broad dissemination has been reported outside of those settings. We sought to use a voluntary collaborative strategy to disseminatebest practices to reduce overuse of unnecessary care in children hospitalized for bronchiolitis in community settings. METHODS: This project was aquality improvement collaborative consisting of monthly interactive webinars with online data collection and feedback. Data were collected by chart review for 2 bronchiolitis seasons, defined as January, February, and March of 2013 and 2014. Patients aged <24 months hospitalized for bronchiolitis and without chronic illness, prematurity, or intensive care use were included. Results were analyzed using run charting, analysis of means, and nonparametric statistics. RESULTS: There were 21 participating hospitals contributing a total of 1869 chart reviews to the project, 995 preintervention and 874 postintervention. Mean use of any bronchodilator declined by 29% (P = .03) and doses per patient decreased 45% (P < .01). Mean use of any steroids declined by 68% (P < .01), and doses per patient decreased 35% (P = .04). Chest radiography use declined by 44% (P = .05). Length of stay decreased 5 hours (P < .01), and readmissions remained unchanged. CONCLUSIONS: A voluntary collaborative was effective in reducing unnecessary care among a cohort of primarily community hospitals. Such a strategy may be generalizable to the settings where the majority of children are hospitalized in the United States.

Guiding Principles for Pediatric Hospital Medicine Programs

Pediatric hospital medicine programs have an established place in pediatric medicine. This statement speaks to the expanded roles and responsibilities of pediatric hospitalists and their integrated role among the community of pediatricians who care for children within and outside of the hospital setting.

A Proposed Dashboard for Pediatric Hospital Medicine Groups

In February of 2009, the Society of Hospital Medicine, the Section on Hospital Medicine of the American Academy of Pediatrics, and the Academic Pediatric Association sponsored a strategic planning meeting to create a vision of the future for Pediatric Hospital Medicine (PHM). One of the outcomes of that meeting was a mandate to create a dashboard for PHM groups. Given that PHM is the fastest growing area of pediatrics,1 and that pediatric hospitalists and their groups are becoming responsible for more patients and more processes in hospitals,2 an important part of the growth of the specialty will be continuous improvement and monitoring. As with all areas of medicine, improvement comes from identification of gaps in performance or services and the subsequent improvement cycles that follow. This proposed dashboard attempts to build a framework for groups to monitor, compare, and improve performance. In addition to groups monitoring their own performance over time, it is envisioned that, as groups begin to populate this dashboard, there will be a transparent repository for the dashboards that allow for comparison among similar groups. In July 2009, a call for participation in the creation of the dashboard was sent to the PHM Listserv of the American Academy of Pediatrics. In addition to the 3 original hospitalists named to start the project (P.H., J.D., E.R.), 8 others volunteered to form the PHM Dashboard Committee (the Committee).The Committee met numerous times via conference call and agreed to the following guiding principles: 1. The dashboard should be as broadly applicable as possible 2. The dashboard should focus on the PHM group, and not the individual hospitalist 3. The dashboard should use the simplest possible methods for achieving measurement aims 4. Dashboard items should be selected and/or customized to best help each unique PHM group: each group’s dashboard may look different Subsequently, …

What Works to Reduce Unnecessary Care for Bronchiolitis? A Qualitative Analysis of a National Collaborative

OBJECTIVE Unnecessary care is well established as a quality problem affecting acute viral bronchiolitis, one of the most common pediatric illnesses. Although there is an extensive quality improvement literature on the disease, published work primarily reflects the experience of freestanding childrens hospitals. We sought to better understand the specific barriers and drivers for successful quality improvement in community and nonfreestanding childrens facilities. METHODS We undertook a mixed methods study to identify correlates of success in a bronchiolitis quality improvement collaborative of community hospitals and childrens hospitals within adult hospitals. We assessed site demographic characteristics, compliance with project interventions, and team engagement for association with end of project performance. We then used performance quartiles on a composite assessment of project measures (use of bronchodilators and steroids) to design a purposive sample of sites approached for qualitative interviews. RESULTS Team engagement was the only factor quantitatively associated with better performance in the overall cohort. Fifteen sites, from the total cohort of 21, completed qualitative interviews. Qualitative themes around team engagement, including the presence of buy-in for successful sites and the inability to engage colleagues at unsuccessful sites, were important differentiating factors between top and bottom performance quartiles. Regardless of performance quartile, most programs cited intrainstitutional competition for limited resources to do quality improvement work as a specific barrier for pediatrics. The ability to overcome such barriers and specifically garner information technology (IT) resources also differentiated the top and bottom performance quartiles. CONCLUSIONS Team engagement showed a consistent association with success across our quantitative and qualitative evaluations. Competition for limited resources in this cohort of nonfreestanding childrens programs, particularly those in hospital IT, was a key qualitative theme.

Taking Chances With Strep Throat

A previously healthy 22-month-old male child presented in the summer to his pediatrician’s office with an acute febrile illness. Results of the physical examination were normal except for rhinorrhea, but because of the fever, the pediatrician performed a rapid antigen strep test. The test result was positive, and 10 days of amoxicillin/clavulanic acid were prescribed. After 7 days on the antibiotic, the patient developed a diffuse, erythematous rash on his trunk and extremities; he was taken to the emergency department, where he was prescribed oral steroids for the rash. The following morning, his pediatrician diagnosed the rash as a drug reaction and discontinued the amoxicillin/clavulanic acid and started azithromycin to complete the treatment course for group A streptococcus (GAS) pharyngitis or “strep throat.” The following day, the patient’s rash became more widespread and pruritic. A third visit with the pediatrician was scheduled, and erythema multiforme was diagnosed. The patient was nontoxic appearing, but the pediatrician decided to admit him to complete the treatment course for strep throat along with possible intravenous steroids as therapy for the erythema multiforme. On admission, the patient was noted to have an impressive rash without oral or ocular involvement and was otherwise well-appearing. Ultimately, a tactful discussion with the admitting pediatrician revealed that the preferred course for all parties would be discontinuation of antibiotics and steroids, and the patient was then discharged from the hospital. In the practice of medicine, we should attempt to weigh the risks and benefits of each patient management decision. This particular case brings up various opportunities in which decisions might have been made differently if both the potential risks and benefits of the treatment were considered more explicitly. First, what were the chances that this child had strep throat? A positive rapid strep test result may indicate true infection or …

Implementing Parental Tobacco Dependence Treatment Within Bronchiolitis QI Collaboratives

Systematic tobacco dependence interventions directed at parents and/or caregivers were implemented as secondary aims in multicenter QI collaboratives targeted at improving care for children with bronchiolitis. BACKGROUND AND OBJECTIVES: We sought to implement systematic tobacco dependence interventions for parents and/or caregivers as secondary aims within 2 multisite quality improvement (QI) collaboratives for bronchiolitis. We hypothesized that iterative improvements in tobacco dependence intervention strategies would result in improvement in outcomes between collaboratives. METHODS: This study involved 2 separate yearlong, multisite QI collaboratives that were focused on care provided to inpatients with a primary diagnosis of bronchiolitis. In each collaborative, we provided tools and training in tobacco dependence treatment and expert coaching on interventions for parents as a secondary aim. Data were collected by chart review and results analyzed by using analysis of means and statistical process control analysis. Outcomes between collaboratives were compared by using relative risks. RESULTS: Between both collaboratives, 56 hospitals participated and 6258 inpatient charts were reviewed. In the first collaborative, 22% of identified parents who smoke received tobacco dependence interventions at baseline. This rate increased to 51% during the postintervention period, with special cause revealed by analysis of means. In the second collaborative, 31% of parents who smoke received baseline interventions. This rate increased to 53% by the conclusion of the collaborative, with special cause revealed by statistical process control analysis. The relative risk for providing any cessation intervention in 1 collaborative versus the other was 0.9 (confidence interval 0.8–1.1). CONCLUSIONS: Tobacco dependence treatment of parents and/or caregivers can be integrated into bronchiolitis QI by using relatively low-resource strategies. Using a more intensive QI intervention did not alter the rates of screening or intervention for caregivers who smoke.

Chest Radiograph for Childhood Pneumonia: Good, but Not Good Enough

* Abbreviations: CAP — : community-acquired pneumonia CXR — : chest radiograph ED — : emergency department NPV — : negative predictive value Pneumonia is the greatest killer of children worldwide,1 with 920 136 deaths in children in 2015.2 Although less lethal in developing countries like the United States, the burden is still considerable, with annual ambulatory visit rates for community-acquired pneumonia (CAP) in US children of 16.9 to 22.4 per 1000 in the population.3 Although CAP is a clinical diagnosis, individual signs and symptoms have poor prognostic value,4 and children may undergo radiography to confirm or disprove the diagnosis. Although both viruses and bacteria can cause CAP, physicians are generally trying to rule out a bacterial infection with a chest radiograph (CXR) because the main clinical decision is whether to prescribe antibiotics. Some physicians may be concerned that CXRs can have false-negative results in the early stages of CAP or in the setting of dehydration.5 To address these concerns, Lipsett et al6 report the results of a prospective observational cohort study in children 3 months to 18 years of age undergoing CXR for suspected CAP. The primary outcome was a clinical diagnosis of pneumonia during the … Address correspondence to Matthew D. Garber, MD, Division of Hospital Pediatrics, Wolfson Children’s Hospital, Third Floor, 800 Prudential Dr, Jacksonville, FL 32207. E-mail: matthew.garber{at}jax.ufl.edu

Primer in Patient Safety Concepts: Simulation Case-Based Training for Pediatric Residents and Fellows

Introduction Health care quality and patient safety remain one of the core areas of focus for the Accreditation Council for Graduate Medical Education. In addition to using the traditional approach to teaching patient safety, disclosure of a safety event and introduction to the concepts of just culture and safely doing less add a unique perspective to our module. Methods This 4-hour learning activity was conducted using a formal PowerPoint presentation, simulation, and interactive discussion/debriefing. The presentation reviewed safety concepts and introduced learners to the concepts of just culture and safely doing less. The first case was a standard scenario in which participants assessed a sick but stable child and evaluated the use of premature closure bias that might preclude them from making the correct diagnosis. The second case represented disclosure of a medical error. Participants were evaluated on their communication/professionalism skills and challenged to discover overuse as one of the root causes of medication error. Pre- and posttest surveys were used for learner evaluation. Results Participants showed significant improvement on content-based questions, increasing from 51.7% to 69.3% correct (p < .001). After Bonferroni correction, only the question on overdiagnosis showed significant improvement (p = .001). Participants reported significantly increased confidence in all areas evaluated (p < .001). Discussion Participants placed high value on the workshop. The question on overdiagnosis showed significant improvement on the posttest. The concepts of patient safety, just culture, and safely doing less can be introduced to learners at a formative stage in their career through simulation.