Paul S. Kurtin

PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations.

Background.The PedsQL (Pediatric Quality of Life Inventory) (Children’s Hospital and Health Center, San Diego, California) is a modular instrument for measuring health-related quality of life (HRQOL) in children and adolescents ages 2 to 18. The PedsQL 4.0 Generic Core Scales are multidimensional child self-report and parent proxy-report scales developed as the generic core measure to be integrated with the PedsQL Disease-Specific Modules. The PedsQL 4.0 Generic Core Scales consist of 23 items applicable for healthy school and community populations, as well as pediatric populations with acute and chronic health conditions. Methods.The 4 PedsQL 4.0 Generic Core Scales (Physical, Emotional, Social, School) were administered to 963 children and 1,629 parents (1,677 subjects accrued overall) recruited from pediatric health care settings. Item-level and scale-level measurement properties were computed. Results.Internal consistency reliability for the Total Scale Score (&agr; = 0.88 child, 0.90 parent report), Physical Health Summary Score (&agr; = 0.80 child, 0.88 parent), and Psychosocial Health Summary Score (&agr; = 0.83 child, 0.86 parent) were acceptable for group comparisons. Validity was demonstrated using the known-groups method, correlations with indicators of morbidity and illness burden, and factor analysis. The PedsQL distinguished between healthy children and pediatric patients with acute or chronic health conditions, was related to indicators of morbidity and illness burden, and displayed a factor-derived solution largely consistent with the a priori conceptually-derived scales. Conclusion.The results demonstrate the reliability and validity of the PedsQL 4.0 Generic Core Scales. The PedsQL 4.0 Generic Core Scales may be applicable in clinical trials, research, clinical practice, school health settings, and community populations.

A quality improvement project to increase breast milk use in very low birth weight infants.

OBJECTIVE: To evaluate a multihospital collaborative designed to increase breast milk feeding in premature infants. METHODS: Eleven NICUs in the California Perinatal Quality of Care Collaborative participated in an Institute for Healthcare Improvement–style collaborative to increase NICU breast milk feeding rates. Multiple interventions were recommended with participating sites implementing a self-selected combination of these interventions. Breast milk feeding rates were compared between baseline (October 2008–September 2009), implementation (October 2009–September 2010), and sustainability periods (October 2010–March 2011). Secondary outcome measures included necrotizing enterocolitis (NEC) rates and lengths of stay. California Perinatal Quality of Care Collaborative hospitals not participating in the project served as a control population. RESULTS: The breast milk feeding rate in the intervention sites improved from baseline (54.6%) to intervention period (61.7%; P = .005) with sustained improvement over 6 months postintervention (64.0%; P = .003). NEC rates decreased from baseline (7.0%) to intervention period (4.3%; P = .022) to sustainability period (2.4%; P < .0001). Length of stay increased during the intervention but returned to baseline levels in the sustainability period. Control hospitals had higher rates of breast milk feeding at baseline (64.2% control vs 54.6% participants, P < .0001), but over the course of the implementation (65.7% vs 61.7%, P = .049) and sustainability periods (67.7% vs 64.0%, P = .199), participants improved to similar rates as the control group. CONCLUSIONS: Implementation of a breast milk/nutrition change package by an 11-site collaborative resulted in an increase in breast milk feeding and decrease in NEC that was sustained over an 18-month period.

Measuring quality of care for vulnerable children: challenges and conceptualization of a pediatric outcome measure of quality.

This article addresses conceptual and practical issues in the assessment of pediatric health care quality, outlines a conceptual model for measuring quality, and describes on-going research to validate an outcome measure of health care quality for vulnerable children. Pediatric quality measurement is distinct from that for adults due to development, dependence, differential epidemiology, demographic factors, and differences between the child and adult health services systems. A noncategorical approach to quality measurement, rather than one based on illness status or specific condition, is necessary to adequately measure quality for the majority of children, both healthy and ill. One promising noncategorical measure of pediatric health care quality is health outcome, specifically health-related quality of life (HRQOL). The Pediatric Quality of Life Inventory (PedsQL), a brief, practical, reliable, valid, generic pediatric HRQOL measure, is a suitable candidate measure. Ongoing research to validate the PedsQL as an outcome measure of health care quality is described.

Standardize to Excellence: Improving the Quality and Safety of Care with Clinical Pathways

Providing practitioners with locally developed, consensus-driven, evidence-based clinical pathways can improve the quality of care by (1) incorporating national guidelines and recommendations into routine care practices, increasing the use of validated practice; 2) reducing unnecessary variation in care by a single physician or group of physicians, improving efficiency and timeliness and reducing disparities; and (3) standardizing care processes, improving safety. Pathways make it easier to identify opportunities for future improvements in care processes while simultaneously making those improvements easier to enact. Pediatric hospitalists have a vital role in creating, implementing, evaluating, and improving clinical pathways. Involving house staff enriches the scholarly components of pathway development while actively engaging them in the science and practice of quality improvement.

Implementation Methods for Delivery Room Management: A Quality Improvement Comparison Study

BACKGROUND: There is little evidence to compare the effectiveness of large collaborative quality improvement versus individual local projects. METHODS: This was a prospective pre-post intervention study of neonatal resuscitation practice, comparing 3 groups of nonrandomized hospitals in the California Perinatal Quality Care Collaborative: (1) collaborative, hospitals working together through face-to-face meetings, webcasts, electronic mailing list, and data sharing; (2) individual, hospitals working independently; and (3) nonparticipant hospitals. The collaborative and individual arms participated in improvement activities, focusing on reducing hypothermia and invasive ventilatory support. RESULTS: There were 20 collaborative, 31 individual, and 44 nonparticipant hospitals caring for 12 528 eligible infants. Each group had reduced hypothermia from baseline to postintervention. The collaborative group had the most significant decrease in hypothermia, from 39% to 21%, compared with individual hospital efforts of 38% to 33%, and nonparticipants of 42% to 34%. After risk adjustment, the collaborative group had twice the magnitude of decrease in rates of newborns with hypothermia compared with the other groups. Collaborative improvement also led to greater decreases in delivery room intubation (53% to 40%) and surfactant administration (37% to 20%). CONCLUSIONS: Collaborative efforts resulted in larger improvements in delivery room outcomes and processes than individual efforts or nonparticipation. These findings have implications for planning quality improvement projects for implementation of evidence-based practices.

Neonatal Intensive Care Unit Collaboration to Decrease Hospital-Acquired Bloodstream Infections: From Comparative Performance Reports to Improvement Networks

This two-part article provides a general guide to thinking about data-driven clinical performance evaluation and describes two statewide improvement networks anchored in such comparisons. Part 1 examines key ideas for making fair comparisons among providers. Part 2 describes the development of a data-driven collaborative that aims to reduce central line associated bloodstream infections in neonatal ICUs across New York State, and a more mature collaborative in California that has already succeeded in reducing these infections; it provides sufficient detail and tools to be of practical help to others seeking to create such networks. The content illustrates concepts with broad applicability for pediatric quality improvement.

Rapid Assessment with Qualitative Telephone Interviews: Lessons from an Evaluation of California’s Healthy Families Program & Medi-Cal for Children

California’s Healthy Families/Medi-Cal for Children (HF/MCC) program provides low- and no-cost health insurance to low-income children. In December 1999 and January 2000, 72 community-based organizations (CBOs) were contracted by California’s Department of Health Services (DHS) to supply culturally appropriate HF/MCC outreach and enrollment services. This article describes the incorporation of a qualitative telephone interview component for rapid assessment purposes after the planned quantitative analysis of program records faltered in 2001 due to missing, invalid, and unreliable data. We describe the rapid interview protocol and discuss benefits and barriers. The protocol can serve as a model for others interested in using rapid qualitative telephone interviews within their own evaluation efforts.

Developing Indicators for Emergency Medical Services (EMS) System Evaluation and Quality Improvement: A Statewide Demonstration and Planning Project

BACKGROUND The state of California, like every other state, has no system for assessing the quality of prehospital emergency medical services (EMS) care. As part of a statewide project, a process was designed for the evaluation and quality improvement (QI) of EMS in California. Local EMS agency (LEMSA) representatives made a commitment to submit data from both the providers and the hospitals they work with. INDICATOR SELECTION AND DEVELOPMENT For conditions such as cardiac chest complaints, standardized indicators had already been developed, but for many other areas of interest there was either little literature or little consensus in the literature. Definitional differences were often linked to local-practice protocol differences. A related comparison challenge lay in the fact that care protocols may differ across systems. Some aspects of care may not be offered at all, which may reflect resource shortages or variable medical direction. DATA COLLECTION PROCEDURES Each indicator was precisely defined, and definition sheets and data troubleshooting report forms were provided to participants in three data-collection rounds. Participants were given 1 month to collect the data, which consisted of summary-level elements (for example, average time to defibrillation for all patients 15 years or older who received defibrillation in 1998). Data were then aggregated, analyzed, and prepared for display in graphs and tables. ACCESS AND MEASUREMENT ISSUES Numerous data collection problems were encountered. For example, not all participants could actually access data that they thought would be available. Linking data on patients as they travel through the continuum of EMS care (dispatch, field, hospital) and linking EMS data to hospital outcomes was also difficult. Yet even when data were easily available, challenges arose. The need for specificity, the potential misfit between definitions and the available data, and the challenges of data retrieval remained salient for the duration of the project and made cross-LEMSA and cross-provider comparison problematic. RECOMMENDATIONS AND LESSONS LEARNED The project led to formal policy recommendations regarding development of a state-defined minimum data set of structure, process, and outcome indicators and their associated data elements; provision in the minimum data set for both local-level and statewide indicators; and provision of technical assistance at the local-provider level. EPILOGUE Since the projects conclusion in June 2000, many regional and local EMS groups have begun to collect data on indicators. Many of the projects recommendations have been incorporated into the work plan of the states System Review and Data Committee.

Carnitine Metabolism and Usage in Chronic Dialysis Patients

Chronic dialysis patients typically have numerous nutritional disturbances including abnormal lipid metabolism. They may also experience adverse clinical consequences of hemodialysis including intradialytic hypotension, muscle cramping, cardiac arrhythmias, as well as generalized fatigue following dialytic therapy. These symptoms may, in part, be related to abnormal muscle metabolism. Recently, carnitine deficiency has been proposed as a link between some of the adverse nutritional-biochemical consequences of end-stage renal disease and the untoward clinical events listed above. Carnitine, 3-hydroxy-4-N-trimethylaminobutyric acid, is required for shuttling long-chain fatty acids across the inner mitochondria1 membrane for subsequent P-oxidation and the provision of cellular energy. Carnitine’s carrier function in fatty acid metabolism is shown in Figure 1. Carnitine also plays a role in branched-chain amino acid metabolism and gluconeogenesis (1). Carnitine is not an essential nutrient because it can be synthesized de novo from the amino acids lysine and methionine. Preformed carnitine can be obtained from red meats, which are particularly rich in carnitine, or dairy products. Little, if any, carnitine is found in vegetable products. In tissues and biologic fluids, carnitine is present in a free form as the L-isomer and in an esterified form as shortor long-chain fatty acid acyl-carnitine. Synthetic carnitine may consist of a racemic mixture of Dand L-isomers, or more recently, as L-carnitine alone.

Assessing patient outcomes with higher hematocrit levels

Quality improvement theory teaches that, as providers of health care, physicians must determine and then meet the needs of their primary customers, the patients and payers. The needs of patients and payers are met and measured by the outcome of services and treatments delivered by providers to patients. In general, outcomes fall into three main categories: clinical, financial, and patient based. All parties within the end-stage renal disease (ESRD) community seek the best value (quality/cost) when receiving, delivering, or paying for ESRD services. Because there is not yet a consensus on the definition(s) of quality in the care of ESRD patients, a determination of value remains largely cost dependent. Thus payers, who have no easy or reliable way to compare the quality of providers, based many of their decisions on the best available price. Patient-based outcomes include the assessment of patient satisfaction and health status (health-related quality of life). These outcomes broaden the perspective on quality of care beyond the clinical and laboratory measures traditionally used in the ESRD Program. The assessment of these outcomes can give providers additional insights into the burdens of renal failure and its treatment on the lives of their patients. This information then can be used to design or modify the services provided. Physicians are required to provide high-quality, effective, appropriate, and cost-efficient services. How to meet the often conflicting outcome needs of payers and patients remains a significant challenge. It is essential that all within the ESRD community reach some agreement on the operational definition(s) of quality process and outcome indicators.(ABSTRACT TRUNCATED AT 250 WORDS)