Patricia Li

Follow-Up Care after an Emergency Department Visit for Asthma and Subsequent Healthcare Utilization in a Universal-Access Healthcare System

OBJECTIVES To describe the follow-up care within 28 days of an emergency department (ED) visit for asthma and to determine the association of follow-up visits within 28 days with ED re-visits and hospital admissions in the subsequent year. STUDY DESIGN Population-based retrospective cohort study of children with asthma aged 2-17 years treated in an ED in Ontario, Canada between April 14, 2006 and February 28, 2009. Multiple linked health administrative datasets and Cox proportional hazard multivariable survival models were used to test the association of characteristics of 28-day follow-up visits with 1-year outcomes. RESULTS The final cohort consisted of 29391 children, of whom 32.8% had follow-up, 6496 (22.1%) had an ED re-visit, and 801 (2.7%) had a hospital admission. Having a follow-up visit was not associated with ED re-visit or hospitalizations (hazard ratio 0.98; 95% CI 0.93, 1.03 and hazard ratio 1.06; 95% CI 0.92, 1.23, respectively). Younger children and those with indices of more severe acute or chronic asthma were more likely to have ED re-visits and hospitalizations. Other follow-up care characteristics (number of visits, type of physician providing care) were not associated with outcomes. CONCLUSIONS Despite a universal healthcare setting, most children did not access follow-up care after an ED visit for asthma, and those that did had no associated benefit in terms of reduced ED re-visits and hospitalizations in the subsequent year.

Point-of-care lung ultrasound in young children with respiratory tract infections and wheeze

Objective Characterise lung ultrasound (LUS) findings, diagnostic accuracy and agreement between novice and expert interpretations in young children with respiratory tract infections and wheeze. Methods Prospective cross-sectional study in a paediatric ED. Patients ≤2 years with a respiratory tract infection and wheeze at triage were recruited unless in severe respiratory distress. Prior to clinical management, a novice sonologist performed the LUS using a six-zone scanning protocol. The treating physician remained blinded to ultrasound findings; final diagnoses were extracted from the medical record. An expert sonologist, blinded to all clinical information, assessed the ultrasound video clips at study completion. Positive LUS was defined as the presence of ≥1 of the following findings: ≥3 B-lines per intercostal space, consolidation and/or pleural abnormalities. Results Ninety-four patients were enrolled (median age 11.1 months). LUS was positive in 42% (39/94) of patients (multiple B-lines in 80%, consolidation in 64%, pleural abnormalities in 23%). The proportion of positive LUS, along with their diagnostic accuracy (sensitivity (95% CI), specificity (95% CI)), were as follows for children with bronchiolitis, asthma, pneumonia and asthma/pneumonia: 46% (45.8% (34.0% to 58.0%), 72.7% (49.8% to 89.3%)), 0% (0% (0.0% to 23.3%), 51.3% (39.8% to 62.6%)), 100% (100% (39.8% to 100.0%), 61.1% (50.3% to 71.2%)), 50% (50% (6.8% to 93.2%), 58.9% (48.0% to 69.2%)), respectively. There was good agreement between the novice and expert sonographers for a positive LUS (kappa 0.68 (95% CI 0.54 to 0.82)). Conclusions Among children with respiratory tract infections and wheeze, a positive LUS seems to distinguish between clinical syndromes by ruling in pneumonia and ruling out asthma. If confirmed in future studies, LUS may emerge as a point-of-care tool to guide diagnosis and disposition in young children with wheeze.

Recent innovations to improve asthma outcomes in vulnerable children

Purpose of review Despite overall improvements in asthma care through an increasing evidence base, disparities in outcomes of children of ethnic minorities and low socioeconomic status are well documented across healthcare systems. New interventions to reduce gaps in outcomes among these children are continually being evaluated. This article reviews the most relevant and influential recent studies. Recent findings A number of interventions aimed at vulnerable children with asthma have been successful. Most of these include a component of education and self-management. There is some evidence that culturally competent care produces improved outcomes, whereas stronger evidence exists for multifaceted programs and community health workers providing home visits for education and environmental allergen reduction. Targeting children and families through school-based programs may be an effective outreach strategy. Use of novel technologies such as educational messages on MP3 players shows promise in reaching at-risk adolescents. Summary There are promising strategies proven to significantly decrease disparities in asthma among vulnerable children. Further research must be performed to elucidate the interventions that produce the greatest impact on asthma-related outcomes while being feasible, sustainable, and cost-effective.

Association Between Evidence-Based Standardized Protocols in Emergency Departments With Childhood Asthma Outcomes: A Canadian Population-Based Study

OBJECTIVE To determine whether children treated in emergency departments (EDs) with evidence-based standardized protocols (EBSPs) containing evidence-based content and format had lower risk of hospital admission or ED return visit and greater follow-up than children treated in EDs with no standardized protocols in Ontario, Canada. DESIGN Retrospective population-based cohort study of children with asthma. We used multivariable logistic regression to estimate risk of outcomes. SETTING All EDs in Ontario (N = 146) treating childhood asthma from April 2006 to March 2009. PARTICIPANTS Thirty-one thousand one hundred thirty-eight children (aged 2 to 17 years) with asthma. MAIN EXPOSURE Type of standardized protocol (EBSPs, other standardized protocols, or none). MAIN OUTCOME MEASURES Hospital admission, high-acuity 7-day return visit to the ED, and 7-day outpatient follow-up visit. RESULTS The final cohort made 46 510 ED visits in 146 EDs. From the index ED visit, 4211 (9.1%) were admitted to the hospital. Of those discharged, 1778 (4.2%) and 7350 (17.4%) had ED return visits and outpatient follow-up visits, respectively. The EBSPs were not associated with hospitalizations, return visits, or follow-up (adjusted odds ratio, 1.17 [95% CI, 0.91-1.49]; adjusted odds ratio, 1.10 [95% CI, 0.86-1.41]; and adjusted odds ratio, 1.08 [95% CI, 0.87-1.35], respectively). CONCLUSIONS The EBSPs were not associated with improvements in rates of hospital admissions, return visits to the ED, or follow-up. Our findings suggest the need to address gaps linking improved processes of asthma care with outcomes.

Team-based versus traditional primary care models and short-term outcomes after hospital discharge

BACKGROUND: Strategies to reduce hospital readmission have been studied mainly at the local level. We assessed associations between population-wide policies supporting team-based primary care delivery models and short-term outcomes after hospital discharge. METHODS: We extracted claims data on hospital admissions for any cause from 2002 to 2009 in the province of Quebec. We included older or chronically ill patients enrolled in team-based or traditional primary care practices. Outcomes were rates of readmission, emergency department visits and mortality in the 90 days following hospital discharge. We used inverse probability weighting to balance exposure groups on covariates and used marginal structural survival models to estimate rate differences and hazard ratios. RESULTS: We included 620 656 index admissions involving 312 377 patients. Readmission rates at any point in the 90-day post-discharge period were similar between primary care models. Patients enrolled in team-based primary care practices had lower 30-day rates of emergency department visits not associated with readmission (adjusted difference 7.5 per 1000 discharges, 95% confidence interval [CI] 4.2 to 10.8) and lower 30-day mortality (adjusted difference 3.8 deaths per 1000 discharges, 95% CI 1.7 to 5.9). The 30-day difference for mortality differed according to morbidity level (moderate morbidity: 1.0 fewer deaths per 1000 discharges in team-based practices, 95% CI 0.3 more to 2.3 fewer deaths; very high morbidity: 4.2 fewer deaths per 1000 discharges, 95% CI 3.0 to 5.3; p < 0.001). INTERPRETATION: Our study showed that enrolment in the newer team-based primary care practices was associated with lower rates of postdischarge emergency department visits and death. We did not observe differences in readmission rates, which suggests that more targeted or intensive efforts may be needed to affect this outcome.

Risk of ketoacidosis in children at the time of diabetes mellitus diagnosis by primary caregiver status: a population-based retrospective cohort study

BACKGROUND: Diabetic ketoacidosis is the leading cause of death among children with type 1 diabetes mellitus, and is an avoidable complication at first-time diagnosis of diabetes. Because having a usual provider of primary care is important in improving health outcomes for children, we tested the association between having a usual provider of care and risk of diabetic ketoacidosis at onset of diabetes. METHODS: Using linked health administrative data for the province of Quebec, we conducted a population-based retrospective cohort study of children aged 1–17 years in whom diabetes was diagnosed from 2006 to 2015. We estimated adjusted risk ratios (RRs) for an episode of diabetic ketoacidosis at the time of diabetes diagnosis in relation to usual provider of care (family physician, pediatrician or none) using Poisson regression models with robust error variance. RESULTS: We identified 3704 new cases of diabetes in Quebec children from 2006 to 2015. Of these, 996 (26.9%) presented with diabetic ketoacidosis. A decreased risk of this complication was associated with having a usual provider of care; the association was stronger with increasing age, reaching statistical significance among those aged 12–17 years. Within this age group, those who had a family physician or a pediatrician were 31% less likely (adjusted RR 0.69, 95% confidence interval [CI] 0.56–0.85) or 38% less likely (adjusted RR 0.62, 95% CI 0.45–0.86), respectively, to present with diabetic ketoacidosis, relative to those without a usual provider of care. INTERPRETATION: For children with newly diagnosed diabetes, having a usual provider of care appears to be important in decreasing the risk of diabetic ketoacidosis at the time of diabetes diagnosis. Our results provide further evidence concerning the need for initiatives that promote access to primary care for children.

Medical Practice Variations in Pediatric Care

The study of pediatric medical practice variation began with reports on tonsillectomy rates in children almost a century ago. However, the majority of studies have only been conducted in the past two decades. The study of variations is important in revealing problems with healthcare systems and practice, and can be used to improve processes and outcomes in the care of children. However, there are some key issues that have hindered growth in pediatric variation studies, such as matters related to the ecology of disease and healthcare use unique to children, the paucity of evidence-based care, the relative lack of child health services capacity and population-based data, and other issues related to child health research in general (the four “D”s, which include Differential epidemiology, Developmental change, Dependency, and Demographics). This chapter examines methodological issues in child health and health services research that have challenged the study of pediatric practice variations, and examines variations in terms of effective care, preference-based care, and supplysensitive care as it pertains to primary care and hospital care of children. Consideration of how