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Atmanli A, Yen K, Zhou AZ. Diagnostic testing for chest pain in a pediatric emergency department and rates of cardiac disease before and during the COVID-19 pandemic: a retrospective study. Front Pediatr 2024; 12:1366953. [PMID: 38745831 PMCID: PMC11091279 DOI: 10.3389/fped.2024.1366953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/19/2024] [Indexed: 05/16/2024] Open
Abstract
Objectives Chest pain is a common chief complaint in pediatric emergency departments (EDs). Coronavirus disease-2019 (COVID-19) has been shown to increase the risk of cardiac disease. It remains unclear how COVID-19 changed how pediatric emergency clinicians approach patients presenting with chest pain. The goal of this study was to characterize the diagnostic testing for chest pain in a pediatric ED before and during the COVID-19 pandemic. Methods This was a retrospective study of children between the ages of 2-17 years presenting to a pediatric ED from 1/1/2018-2/29/2020 (Pre-COVID-19) and 3/1/2020-4/30/2022 (COVID-19) with chest pain. We excluded patients with a previous history of cardiac disease. Results Of the 10,721 encounters during the study period, 5,692 occurred before and 5,029 during COVID-19. Patient demographics showed minor differences by age, weight, race and ethnicity. ED encounters for chest pain consisted of an average of 18% more imaging studies during COVID-19, including 14% more EKGs and 11% more chest x-rays, with no difference in the number of echocardiograms. Compared to Pre-COVID-19, 100% more diagnostic tests were ordered during COVID-19, including cardiac markers Troponin I (p < 0.001) and BNP (p < 0.001). During COVID-19, 1.1% of patients had a cardiac etiology of chest pain compared with 0.7% before COVID-19 (p = 0.03). Conclusions During COVID-19, pediatric patients with chest pain underwent more diagnostic testing compared to Pre-COVID-19. This may be due to higher patient acuity, emergence of multisystem inflammatory syndrome in children (MIS-C) that necessitated more extensive testing and possible changes in ED clinician behavior during COVID-19.
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Affiliation(s)
- Ayhan Atmanli
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Kenneth Yen
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Amy Z Zhou
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
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2
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Alsabri M, Elshanbary AA, Nourelden AZ, Fathallah AH, Zaazouee MS, Pincay J, Nakadar Z, Wasem M, Aeder L. Chest pain in pediatric patients in the emergency department- Presentation, risk factors and outcomes-A systematic review and meta-analysis. PLoS One 2024; 19:e0294461. [PMID: 38626180 PMCID: PMC11020527 DOI: 10.1371/journal.pone.0294461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 10/31/2023] [Indexed: 04/18/2024] Open
Abstract
OBJECTIVE This study aimed to assess and determine the presentation, risk factors, and outcomes of pediatric patients who were admitted for cardiac-related chest pain. BACKGROUND Although chest pain is common in children, most cases are due to non-cardiac etiology. The risk of misdiagnosis and the pressure of potentially adverse outcomes can lead to unnecessary diagnostic testing and overall poorer patient experiences. Additionally, this can lead to a depletion of resources that could be better allocated towards patients who are truly suffering from cardiac-related pathology. METHODS This review was conducted per PRISMA guidelines. This systematic review used several databases including MEDLINE, Embase, Scopus, and Web of Science to obtain its articles for review. RESULTS A total of 6,520 articles were identified, and 11 articles were included in the study. 2.5% of our study population was found to have cardiac-related chest pain (prevalence = 0.025, 95% CI [0.013, 0.038]). The most commonly reported location of pain was retrosternal chest pain. 97.5% of the study population had a non-cardiac cause of chest pain, with musculoskeletal pain being identified as the most common cause (prevalence = 0.357, 95% CI [0.202, 0.512]), followed by idiopathic (prevalence = 0.352, 95% CI [0.258, 0.446]) and then gastrointestinal causes (prevalence = 0.053, 95% CI [0.039, 0.067]). CONCLUSIONS The overwhelming majority of pediatric chest pain cases stem from benign origins. This comprehensive analysis found musculoskeletal pain as the predominant culprit behind chest discomfort in children. Scrutinizing our study cohort revealed that retrosternal chest pain stands as the unequivocal epicenter of this affliction. Thorough evaluation of pediatric patients manifesting with chest pain is paramount for the delivery of unparalleled care, especially in the context of potential cardiac risks in the emergency department.
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Affiliation(s)
- Mohammed Alsabri
- Department of Pediatrics/Emergency Pediatrics, Althawra Modern General Hospital, Sana’a, Yemen
| | | | | | | | | | - Jorge Pincay
- SUNY Downstate Health Sciences University, Brooklyn, NY, United States of America
| | - Zaid Nakadar
- SUNY Downstate Health Sciences University, Brooklyn, NY, United States of America
| | - Muhammad Wasem
- Pediatric Emergency Department NYC Health + Hospitals/Lincoln, Bronx, NY, United States of America
| | - Lita Aeder
- Pediatric Department, Brookdale Hospital, Brooklyn, NY, United States of America
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3
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Warren PW, Beck AF, Zang H, Anderson J, Statile C. Inequitable access: factors associated with incomplete referrals to paediatric cardiology. Cardiol Young 2024; 34:428-435. [PMID: 35848164 DOI: 10.1017/s1047951122002037] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To assess the variables associated with incomplete and unscheduled cardiology clinic visits among referred children with a focus on equity gaps. STUDY DESIGN We conducted a retrospective chart review for patients less than 18 years of age who were referred to cardiology clinics at a single quaternary referral centre from 2017 to 2019. We collected patient demographic data including race, an index of neighbourhood socio-economic deprivation linked to a patient's geocoded address, referral information, and cardiology clinic information. The primary outcome was an incomplete clinic visit. The secondary outcome was an unscheduled appointment. Independent associations were identified using multivariable logistic regression. RESULTS There were 10,610 new referrals; 6954 (66%) completed new cardiology clinic visits. Black race (OR 1.41; 95% CI 1.22-1.63), public insurance (OR 1.29; 95% CI 1.14-1.46), and a higher deprivation index (OR 1.32; 95% CI 1.08-1.61) were associated with higher odds of incomplete visit compared to the respective reference groups of White race, private insurance, and a lower deprivation index. The findings for unscheduled visit were similar. A shorter time elapsed from the initial referral to when the appointment was made was associated with lower odds of incomplete visit (OR 0.62; 95% CI 0.52-0.74). CONCLUSION Race, insurance type, neighbourhood deprivation, and time from referral date to appointment made were each associated with incomplete referrals to paediatric cardiology. Interventions directed to understand such associations and respond accordingly could help to equitably improve referral completion.
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Affiliation(s)
- Paul W Warren
- Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 2003, Cincinnati, OH 45229, USA
| | - Andrew F Beck
- General and Community Pediatrics and Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
| | - Huaiyu Zang
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Jeffrey Anderson
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Christopher Statile
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, USA
- Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
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4
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Harahsheh AS, Hamburger EK, de Winter JP. Empowering pediatric providers more: mastering management of common complaints. Eur J Pediatr 2023; 182:4767-4770. [PMID: 37589776 DOI: 10.1007/s00431-023-05158-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Ashraf S Harahsheh
- Division of Cardiology, Department of Pediatrics, Children's National Hospital, 111 Michigan Ave, N.W., Washington, DC, 20010, USA.
| | - Ellen K Hamburger
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, 20052, USA
| | - J Peter de Winter
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
- Leuven Child and Youth Institute, KU Leuven, Leuven, Belgium
- Department of Pediatrics, Spaarne Gasthuis, Haarlem and Hoofddorp, The Netherlands
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5
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Ng Q, Loke YH, Smith KL, DeBiasi RL, Berul CI, Sharron MP, Wessel D, Bost JE, Lowndes RW, Ansusinha E, Mehrtens K, Schultz J, Harahsheh AS. Cardiac evaluation of hospitalized children with 2019 coronavirus (COVID-19) infection at a single large quaternary center. Heliyon 2023; 9:e17395. [PMID: 37366529 PMCID: PMC10277255 DOI: 10.1016/j.heliyon.2023.e17395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023] Open
Abstract
Background Cardiac complications of serious SARS-CoV-2 infections, especially Multisystem Inflammatory Syndrome of Children (MIS-C) are well described, however current studies have not considered pediatric patients hospitalized with no cardiac concerns. We established a protocol for cardiac evaluation of all admitted COVID-19 patients three weeks post-discharge, irrespective of cardiac concerns. We assessed cardiovascular outcomes and hypothesized that patients with absent cardiac concerns are at lower risk for cardiac abnormalities. Methods This was a retrospective study of 160 patients admitted for COVID-19 (excluding MIS-C) between March 2020 and September 2021 with subsequent echocardiogram(s) performed at our center. Patients were divided into 4 subgroups: Group 1 included patients with absent cardiac concerns, admitted to acute care (1a) and intensive care unit (ICU) (1 b). Group 2 included patients with cardiac concerns, admitted to acute care (2a) and ICU (2 b). Groups were compared based on clinical endpoints and echocardiographic measurements, including tissue Doppler imaging (TDI) assessment of diastolic function (z-score of septal Mitral E/TDI E' and lateral E/TDI E'). Chi-squared, Fisher's exact, and Kruskal-Wallis tests were used. Results Traditional cardiac abnormalities varied significantly between the groups; with Group 2 b having the most (n = 8, 21%), but still found in Group 1a (n = 2, 3%) and Group 1 b (n = 1, 5%). No patients in Group 1 demonstrated abnormal systolic function, compared to Group 2a (n = 1, 3%) and Group 2 b (n = 3, 9%, p = 0.07). When including TDI assessment of diastolic function, the total incidence of abnormalities found on echocardiogram was increased in all groups. Conclusion Cardiac abnormalities were found in pediatric patients admitted with COVID-19, even those without apparent cardiovascular concerns. The risk was greatest in ICU-admitted patients with cardiac concerns. The clinical significance of diastolic function assessment in these patients remains unknown. Further studies are needed to assess long-term cardiovascular sequelae of children with COVID-19, irrespective of cardiac concerns.
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Affiliation(s)
- Qimin Ng
- Pediatric Residency Program, Medstar Georgetown University Hospital, Washington, DC, USA
| | - Yue-Hin Loke
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Karen L Smith
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Hospital Medicine, Children's National Hospital, Washington, DC, USA
| | - Roberta L DeBiasi
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA
- Department of Microbiology, Immunology and Tropical Medicine, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Charles I Berul
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Matthew P Sharron
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - David Wessel
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - James E Bost
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
- Division of Biostatistics, Children's National Hospital, Washington, DC, USA
| | - Robert W Lowndes
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - Emily Ansusinha
- Division of Infectious Diseases, Children's National Hospital, Washington, DC, USA
| | - Kristine Mehrtens
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
| | - John Schultz
- Division of Ambulatory Services, Children's National Hospital, Washington, DC, USA
| | - Ashraf S Harahsheh
- Division of Cardiology, Children's National Hospital, Washington, DC, USA
- Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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Lubrano R, Martucci V, Marcellino A, Sanseviero M, Sinceri A, Testa A, Frasacco B, Gizzone P, Del Giudice E, Ventriglia F, Bloise S. Emergency Department Admissions of Children with Chest Pain before and during COVID-19 Pandemic. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020246. [PMID: 36832377 PMCID: PMC9955104 DOI: 10.3390/children10020246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/24/2022] [Accepted: 01/28/2023] [Indexed: 01/31/2023]
Abstract
OBJECTIVES We compared the number of accesses, causes, and instrumental evaluations of chest pain in children between the pre-COVID-19 era and the COVID-19 period and analyzed the assessment performed in children with chest pain, highlighting unnecessary examinations. METHODS We enrolled children with chest pain admitted to our emergency department between January 2019 and May 2021. We collected demographic and clinical characteristics and findings on physical examinations, laboratory tests, and diagnostic evaluations. Then, we compared the number of accesses, causes, and instrumental assessments of chest pain between the pre-COVID-19 era and the COVID-19 era. RESULTS A total of 111 patients enrolled (mean age: 119.8 ± 40.48 months; 62 males). The most frequent cause of chest pain was idiopathic (58.55%); we showed a cardiac origin in 4.5% of the cases. Troponin determination was performed in 107 patients, and the value was high only in one case; chest X-rays in 55 cases and echocardiograms in 25 cases showed pathological findings, respectively, in 10 and 5 cases. Chest pain accesses increased during the COVID-19 era (p < 0.0001), with no differences in the causes of chest pain between the two periods. CONCLUSIONS The increase in accesses for chest pain during the COVID-19 pandemic confirms that this symptom generates anxiety among parents. Furthermore, our findings demonstrate that the evaluation of chest pain is still extensive, and new chest pain assessment protocols in the pediatric age group are needed.
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Harahsheh AS. Subspecialty referrals and consultation: it's time to partner with primary care paediatricians. Cardiol Young 2022; 32:1-4. [PMID: 35971911 DOI: 10.1017/s1047951122002578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Ashraf S Harahsheh
- Division of cardiology, Children's National Hospital, Washington, DC, USA and Department of Pediatrics, The George Washington University School of Medicine & Health Sciences, Washington, DC, USA
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8
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Stave EA, Greenberg L, Hamburger E, Ottolini M, Agrawal D, Lewis K, Barber JR, Bost JE, Harahsheh AS. An educational intervention to facilitate appropriate subspecialty referrals: a study assessing resident communication skills. BMC MEDICAL EDUCATION 2022; 22:533. [PMID: 35804336 PMCID: PMC9270829 DOI: 10.1186/s12909-022-03592-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Our goal was to improve pediatric residents' advanced communication skills in the setting of referral to address the entrustable professional activity of subspecialty referral identified by the American Board of Pediatrics. To accomplish this aim, we created a referral and consultation curriculum to teach and assess core communication skills in subspecialty referral involving an adolescent with syncope, an anxiety-provoking symptom that is rarely associated with serious pathology. METHODS We utilized blended multimodal educational interventions to improve resident communication skills in referral of patients. Trainees participated in 1) an interactive online module on syncope focusing on "red-flag" symptoms that would warrant a subspecialty cardiology referral and 2) a 4-h intervention with Standardized Parents (SPs), focusing on the case-based application of communication skills. Communication skills were assessed by two pre- and post- Objective Structured Clinical Examination encounters of patients with syncope, with an SP evaluation using a 20-item checklist. Analysis was performed with Sign test and McNemar's test. Trainees provided feedback on a Critical Incident Questionnaire, which was analyzed qualitatively. RESULTS Sixty-four residents participated. There was an overall improvement in communication skills based on SP scores (82.7 ± 10.9% to 91.7 ± 5.0%, p < 0.001), and 13/20 items demonstrated significant improvement post-intervention. Residents' improved performance enabled them to address patient/family emotions, explain referral logistics, and clarify concerns to agree on a plan. CONCLUSIONS By participating in this curriculum, residents' communication skills improved immediately post-intervention. Further research is needed to assess if this intervention improves patient care by providing residents with enduring skills to judiciously manage the referral process.
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Affiliation(s)
- Elise A Stave
- Pediatrics, Children's National Hospital, Washington, DC, USA
| | - Larrie Greenberg
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ellen Hamburger
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Dewesh Agrawal
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Karen Lewis
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - John R Barber
- Pediatrics, Children's National Hospital, Washington, DC, USA
| | - James E Bost
- Pediatrics, Children's National Hospital, Washington, DC, USA
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Ashraf S Harahsheh
- Pediatrics, Children's National Hospital, Washington, DC, USA.
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
- Division of Cardiology, Children's National Hospital, 111 Michigan Ave, Washington, DC, NW, 20010, USA.
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9
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Chen L, Duan H, Li G, Li X. The Etiology of Chest Pain in Children Admitted to Cardiology Clinics and the Use Echocardiography to Screen for Cardiac Chest Pain in Children. Front Pediatr 2022; 10:882022. [PMID: 35656381 PMCID: PMC9152173 DOI: 10.3389/fped.2022.882022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 04/27/2022] [Indexed: 12/05/2022] Open
Abstract
AIMS Chest pain is a common disease in children. Most cardiac specialists use echocardiography to evaluate the etiology of and screen for children's cardiac chest pain. We analyzed the etiology and echocardiography results of children with chest pain in pediatric cardiology clinics, clarified the disease spectrum and evaluated the diagnostic value of echocardiography in screening cardiac chest pain in children. METHODS AND RESULTS The clinical data of children with chest pain aged younger than 18 years who admitted to the pediatric cardiology clinic of Beijing Anzhen Hospital between 2005 and 2019 were analyzed. The patients were divided into three groups, including the preschool group, the school-age group and the adolescent group. Total 3,477 children were enrolled in this study. 232 (6.7%) patients were caused by cardiac diseases and chest pain was of non-cardiac origin in 3,245 patients (93.3%). The incidence of non-cardiac chest pain in the adolescent group was significantly lower than the other two groups, respectively (91.4 vs. 94.9 vs. 94.3%, P < 0.05). In the preschool group, most of the patients were girls (51.4%), while in the school-age group and the adolescent group, most of the patients were boys (P < 0.05). Among the children (n = 3,205) who underwent echocardiography, 108 children had positive results, and 3,097 children had negative results. Among the 108 positive results, 10 cases of cardiac diseases were related to chest pain. The sensitivity, specificity of echocardiography in the diagnosis of cardiac chest pain were 6.7, and 96.9%, while the positive predictive value and negative predictive value was 12.96 and 93.67%, respectively. CONCLUSION In children with chest pain who are admitted to pediatric cardiology clinics, chest pain is mostly benign and rarely due to cardiac diseases. The use of echocardiography in evaluating cardiac chest pain in children is of little diagnostic value and leads to excess costs for patients and the health care system.
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Affiliation(s)
- Li Chen
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongzhou Duan
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Gang Li
- Department of Pediatric Cardiology Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaoyan Li
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
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10
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Brancato F, De Rosa G, Gambacorta A, Nunziata A, Ferrara P, Buonsenso D, Covino M, Chiaretti A. Role of Troponin Determination to Diagnose Chest Pain in the Pediatric Emergency Department. Pediatr Emerg Care 2021; 37:e1589-e1592. [PMID: 32541399 DOI: 10.1097/pec.0000000000002123] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Chest pain is a common cause to admission to the pediatric emergency department and often leads to an extensive cardiac evaluation. The objective of this study was to evaluate the usefulness of the troponin (TN) plasma level determination in the initial phase of the differential diagnosis of chest pain in children. METHODS This is a retrospective observational study on 107 patients, aged 0 to 19 years, admitted for chest pain to the pediatric emergency department of our institution. Demographics, clinical data, and patient outcomes were analyzed. Troponin values of >0.03 ng/mL but <0.1 ng/mL were considered suspected for cardiac pathology, whereas levels of >0.1 ng/mL were indicative of cardiac pathology. In these latter patients, an echocardiographic examination was also performed. RESULTS Only 99 patients were evaluated with electrocardiogram (ECG). In 91 of 99 patients of our series, both TN determination and ECG recording were performed. Troponin was higher than the cutoff value (0.03 ng/mL) in 9 patients (9.1%). Only 2 of the 9 patients who presented high TN values showed a nonpathological ECG, whereas 16 (17.5%) of 91 patients in whom both ECG and TN determination were performed had ECG abnormalities without a simultaneous elevation of TN. Of the 26 patients who had medical history and suggestive targets of cardiac pathology, only in 6 (23.1%) of them the diagnosis was confirmed. The final diagnosis of the 99 patients was idiopathic chest pain in 45.4% of cases. CONCLUSIONS Even with the low cost and the relatively easiness for the plasma level determination, TN should be measured only in children with chest pain associated to familiar history suggestive of cardiovascular disease and/or clinical symptoms and/or ECG alterations.
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Affiliation(s)
| | | | | | | | | | | | - Marcello Covino
- Emergency Medicine, Fondazione Policlinico Universitario Agostino Gemelli, Istituti di Ricovero e Cura a Carattere Scientifico, Rome, Italy
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11
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Phillips AA, Sable CA, Atabaki SM, Waggaman C, Bost JE, Harahsheh AS. Ambulatory cardiology telemedicine: a large academic pediatric center experience. J Investig Med 2021; 69:1372-1376. [DOI: 10.1136/jim-2021-001800] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/12/2021] [Indexed: 12/31/2022]
Abstract
We performed a retrospective study of cardiology telemedicine visits at a large academic pediatric center between 2016 and 2019 (pre COVID-19). Telemedicine patient visits were matched to data from their previous in-person visits, to evaluate any significant differences in total charge, insurance compensation, patient payment, percent reimbursement and zero reimbursement. Miles were measured between patient’s home and the address of previous visit. We found statistically significant differences in mean charges of telemedicine versus in-person visits (2019US$) (172.95 vs 218.27, p=0.0046), patient payment for telemedicine visits versus in-person visits (2019US$) (11.13 vs 62.83, p≤0.001), insurance reimbursement (2019US$) (65.18 vs 110.85, p≤0.001) and insurance reimbursement rate (43% vs 61%, p=0.0029). Rate of zero reimbursement was not different. Mean distance from cardiology clinic was 35 miles. No adverse outcomes were detected. This small retrospective study showed cost reduction and a decrease in travel time for families participating in telemedicine visits. Future work is needed to enhance compensation for telemedicine visits.
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12
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Harahsheh AS, Hamburger EK, Saleh L, Crawford LM, Sepe E, Dubelman A, Baram L, Kadow KM, Driskill C, Prestidge K, Bost JE, Berkowitz D. Promoting Judicious Primary Care Referral of Patients with Chest Pain to Cardiology: A Quality Improvement Initiative. Med Decis Making 2021; 41:559-572. [PMID: 33655790 DOI: 10.1177/0272989x21991445] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To decrease referrals to cardiology of patients ages 7 to 21 years with low-probability cardiac pathology who presented to primary care with chest pain by 50% within 24 months. STUDY DESIGN A multidisciplinary team designed and implemented an initiative consisting of 1) a decision support tool (DST), 2) educational sessions, 3) routine feedback to improve use of referral criteria, and 4) patient family education. Four pediatric practices, comprising 34 pediatricians and 7 nurse practitioners, were included in this study. We tracked progress via statistical process control charts. RESULTS A total of 421 patients ages 7 to 21 years presented with chest pain to their pediatrician. The utilization of the DST increased from baseline of 16% to 68%. Concurrently, the percentage of low-probability cardiology referrals in pediatric patients ages 7 to 21 years who presented with chest pain decreased from 17% to 5% after our interventions. At a median follow-up time of 0.9 years (interquartile range, 0.3-1.6 years), no patient had a life-threatening cardiac event. CONCLUSION Our health care improvement initiative to reduce low-probability cardiology referrals for children presenting to primary care practices with chest pain was feasible, effective, and safe.
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Affiliation(s)
- Ashraf S Harahsheh
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Children's National Hospital, Washington, DC, USA
| | - Ellen K Hamburger
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Children's National Pediatricians & Associates, Washington, DC, USA
| | - Lena Saleh
- Children's National Hospital, Washington, DC, USA
| | | | - Edward Sepe
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Children's National Pediatricians & Associates, Washington, DC, USA
| | - Ariel Dubelman
- Children's National Pediatricians & Associates, Washington, DC, USA
| | - Lena Baram
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Children's National Pediatricians & Associates, Washington, DC, USA
| | - Kathleen M Kadow
- Children's National Pediatricians & Associates, Washington, DC, USA
| | | | - Kathy Prestidge
- Children's National Pediatricians & Associates, Washington, DC, USA
| | - James E Bost
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Deena Berkowitz
- Department of Pediatrics, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.,Children's National Hospital, Washington, DC, USA
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Chen L, Duan H, Li X, Yang Z, Jiao M, Sun K, Jin M. The Causes of Chest Pain in Children and the Criteria for Targeted Myocardial Enzyme Testing in Identifying the Causes of Chest Pain in Children. Front Cardiovasc Med 2021; 8:582129. [PMID: 33738299 PMCID: PMC7960652 DOI: 10.3389/fcvm.2021.582129] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 02/11/2021] [Indexed: 11/13/2022] Open
Abstract
Aims: Chest pain is a common complaint at pediatric cardiology clinics and often leads to an extensive cardiac evaluation. In this study, we analyzed the causes of chest pain in Chinese children and developed diagnostic procedures and criteria for targeted myocardial enzyme testing. Methods and Results: We retrospectively analyzed the clinical data of patients aged below 18 years visiting our hospital for chest pain between 2005 and 2019. Based on auxiliary exams and clinical diagnosis, we developed diagnostic procedures and criteria for targeted myocardial enzyme testing in children with chest pain. A total of 7,251 children were included in this study. The chest pain was of cardiac origin in 581 patients (8.0%). The incidence of non-cardiac chest pain was significantly higher in the preschool group and the school-age group than in the adolescent group (93.5 vs. 93.8 vs. 90.3%, P < 0.05). Among children with cardiac chest pain, the most common concomitant symptom was chest tightness (67.0%). Myocardial enzyme testing was performed in 5,408 patients and was abnormal in 453 patients. We developed a diagnostic procedure and criteria for targeted myocardial enzyme testing using pertinent history, physical examination, and ECG findings or UCG finding. Applying the diagnostic procedure and criteria could lead to the reduction in myocardial enzyme testing while still capturing all cardiac diagnoses. Conclusion: In children, chest pain is mostly benign and rarely cardiac. During diagnosis, targeted myocardial enzyme testing based on medical history and physical examination can effectively reduce resource use.
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Affiliation(s)
- Li Chen
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hongzhou Duan
- Department of Neurosurgery, Peking University First Hospital, Beijing, China
| | - Xiaoyan Li
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Zuozhen Yang
- Ministry of Education, Laboratory of Biosystem Homeostasis and Protection, College of Life Sciences, Zhejiang University, Hangzhou, China
| | - Meng Jiao
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Kangtai Sun
- Ministry of Science and Technology of the People's Republic of China, Beijing, China
| | - Mei Jin
- Department of Pediatric Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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14
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Powell AW, Pater CM, Chin C, Wittekind SG, Mays WA, Anderson JB, Statile CJ. Implementation of a Pediatric Chest Pain Local Consensus Guideline Decreases the Total Tests Performed Without Negatively Affecting the Yield of Abnormal Cardiac Results. Pediatr Cardiol 2020; 41:1580-1586. [PMID: 32710284 DOI: 10.1007/s00246-020-02414-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/11/2020] [Indexed: 11/28/2022]
Abstract
Pediatric chest pain is common and though usually benign often leads to unnecessary diagnostic testing. There is limited evidence as to whether a local consensus guideline can decrease testing frequency without negatively affecting the overall yield. In addition, it is unknown whether the addition of pulmonary function testing to a cardiopulmonary exercise test increases the diagnostic yield in pediatric patients with chest pain. A retrospective chart review was performed on all new pediatric patients who presented with chest pain at our academic center's pediatric cardiology clinic 18 months before and after the implementation of a standard management guideline. Data from the encounter-associated echocardiogram, cardiopulmonary exercise test, and pulmonary function test, when available, were analyzed. There were no significant differences in patient volume or demographic characteristics in the 18 months before (n = 768) and after (n = 778) guideline implementation. There were significant reductions in the number of ordered echocardiograms (n = 131; 17% vs. n = 75; 9.6%, p < 0.001) and cardiopulmonary exercise tests (n = 46; 6% vs. n = 29; 4%, p = 0.04) with no concerning pathology discovered in either group. Associated pulmonary function testing performed prior to with exercise testing discovered abnormalities in 19% of the total patients tested. The implementation of a local consensus guideline for pediatric chest pain results in fewer unnecessary tests ordered. There was no concerning pathology before or after guideline implementation, therefore conclusions regarding the diagnostic yield of these guidelines are unfeasible. The addition of pulmonary function testing to cardiopulmonary exercise tests increases the potential diagnostic yield in these patients.
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Affiliation(s)
- Adam W Powell
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA. .,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.
| | - Colleen M Pater
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Clifford Chin
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samuel G Wittekind
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Wayne A Mays
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Jeffrey B Anderson
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Christopher J Statile
- Department of Pediatrics, University of Cincinnati College of Medicine, 3333 Burnett Ave., MLC 2003, Cincinnati, OH, USA.,The Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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15
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Anderson S, Figueroa J, McCracken CE, Cochran C, Slesnick TC, Border WL, Sachdeva R. Factors Influencing Temporal Trends in Pediatric Inpatient Imaging Utilization. J Am Soc Echocardiogr 2020; 33:1517-1525. [PMID: 32919851 DOI: 10.1016/j.echo.2020.06.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 06/21/2020] [Accepted: 06/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Concern exists over exponential growth in cardiac imaging in adults, but there is paucity of such data for cardiac imaging trends in pediatric patients. The aims of this study were to determine temporal trends in the use of noninvasive cardiac imaging and compare these with trends in the use of noncardiac imaging and to identify factors influencing those trends using the Pediatric Health Information Service database. METHODS Pediatric inpatient encounter data from January 2004 to December 2017 at 35 pediatric hospitals were extracted from the Pediatric Health Information Service database. Temporal imaging utilization trends in cardiac and noncardiac ultrasound or echocardiography, magnetic resonance imaging (MRI), and computed tomography (CT) were assessed using linear mixed-effects models. Models were adjusted for case-mix index, complex chronic conditions, patient age, length of stay, payer source, and cardiac surgical volume. RESULTS A total of 5,869,335 encounters over 14 years were analyzed (median encounters per center per year, 11,411; median patient age, 4 years; median length of stay, 3 days). From 2004 to 2017, the rates of pediatric inpatient cardiac and noncardiac ultrasound and MRI increased, whereas the rate of noncardiac CT decreased. Cardiac CT use increased beginning in 2014 (+0.264 cardiac CT encounters per 1,000 encounters per year), surpassing the rate of rise of cardiac MRI. Case-mix index, cardiac surgical volume, and payer source affected the largest number of imaging trends. CONCLUSIONS Among pediatric inpatients, utilization of cardiac and noncardiac ultrasound and MRI has steadily increased. Noncardiac CT use declined and cardiac CT use increased after 2014. Factors influencing imaging trends include case-mix index, cardiac surgical volume, and payer source. This study lays a foundation for investigations of imaging-related resource utilization and outcomes among pediatric inpatients.
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Affiliation(s)
- Shae Anderson
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia.
| | - Janet Figueroa
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | | | - Charles Cochran
- Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Timothy C Slesnick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - William L Border
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
| | - Ritu Sachdeva
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia; Children's Healthcare of Atlanta, Sibley Heart Center Cardiology, Atlanta, Georgia
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16
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Abstract
Previous reports have identified risk factors associated with development of post-Fontan protein-losing enteropathy. Less is known about the economic impact and resource utilisation required for post-Fontan protein-losing enteropathy in the current era. We conducted a single-centre retrospective study to assess the impact of post-Fontan protein-losing enteropathy on transplant-free survival. We also described resource utilisation and treatment variations among post-Fontan protein-losing enteropathy patients. Children who received care at our centre between 2009 and 2017 after the Fontan surgery were eligible. Initial admissions for the Fontan operative procedure were excluded. Demographics, hospital admissions, resource utilisation, medications and charges were reviewed. Patients were divided into two groups based on the presence of post-Fontan protein-losing enteropathy. Of the 343 patients screened, 147 met the eligibility criteria. Of these, 28 (19%) developed protein-losing enteropathy. After adjusting for follow-up duration, the protein-losing enteropathy group had higher number of encounters (2.15 ± 2.16 versus 1.47 ± 2.56, p 0.002), hospital length of stay (days) (25 ± 51.3 versus 11.4 ± 41.7, p < 0.0001) and total charges (2018US$) (388,489 ± 759,859 versus 202,725 ± 1,076,625, p < 0.0001). Encounters for patients with protein-losing enteropathy utilised more therapies. Among those with protein-losing enteropathy, use of digoxin was associated with slightly decreased odds for mortality and/or transplant (0.95, confidence interval 0.90-0.99, p 0.021). The 10-year transplant-free survival for patients with/without protein-losing enteropathy was 65.7/97.3% (p 0.002), respectively. Post-Fontan protein-losing enteropathy is associated with reduced 10-year transplant-free survival, higher resource utilisation, charges and medication use compared with the non-protein-losing enteropathy group. Practice variation among post-Fontan protein-losing-enteropathy patients is common. Further larger studies are needed to assess the impact of standardisation on the well-being of children with post-Fontan protein-losing enteropathy.
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17
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Yoon KL. Etiology and treatment of chest pain in children and adolescents. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2020. [DOI: 10.5124/jkma.2020.63.7.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Chest pain is a very common symptom in pediatric patients. Although children with chest pain are relatively unlikely to be suffering from significant cardiac diseases, it is important not to overlook life-threatening diseases. Complete history taking and physical examination––which involves identifying the duration of pain, onset, character, associated symptoms, and aggravating factors––are extremely important. The most common causes of pediatric chest pain are idiopathic and musculoskeletal, while less than 3% of cases are of cardiac origin. Recent studies indicate that chest pain resulted from psychosomatic disorders increases in non-cardiac chest pain in children and adolescents. The reassurance of the benign nature of chest pain is enough in most cases of non-cardiac chest pain in children and adolescents. When echocardiography is performed on patients with exertional chest pain, it is important to confirm the origin of coronary artery to exclude any coronary anomaly. Exertional chest pain, combined syncope, and symptoms of myocardial ischemia should raise the suspicion of significant cardiac diseases. When the chest pain is accompanied by red flag signs, physicians must refer the patients to a pediatric cardiologist.
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18
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O'Byrne ML, Glatz AC, Song L, Griffis HM, Millenson ME, Gillespie MJ, Dori Y, DeWitt AG, Mascio CE, Rome JJ. Association Between Variation in Preoperative Care Before Arterial Switch Operation and Outcomes in Patients With Transposition of the Great Arteries. Circulation 2019; 138:2119-2129. [PMID: 30474422 DOI: 10.1161/circulationaha.118.036145] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The arterial switch operation (ASO) is the gold standard operative correction of neonates with transposition of the great arteries and intact ventricular septum, with excellent operative survival. The associations between patient and surgeon characteristics and outcomes are well understood, but the associations between variation in preoperative care and outcomes are less well studied. METHODS A multicenter retrospective cohort study of infants undergoing neonatal ASO between January 2010 and September 2015 at hospitals contributing data to the Pediatric Health Information Systems database was performed. The association between preoperative care (timing of ASO, preoperative use of balloon atrial septostomy, prostaglandin infusion, mechanical ventilation, and vasoactive agents) and operative outcomes (mortality, length of stay, and cost) was studied with multivariable mixed-effects models. RESULTS Over the study period, 2159 neonates at 40 hospitals were evaluated. Perioperative mortality was 2.8%. Between hospitals, the use of adjuvant therapies and timing of ASO varied broadly. At the subject level, older age at ASO was associated with higher mortality risk (age >6 days: odds ratio, 1.90; 95% CI, 1.11-3.26; P=0.02), cost, and length of stay. Receipt of a balloon atrial septostomy was associated with lower mortality risk (odds ratio, 0.32; 95% CI, 0.17-0.59; P<0.001), cost, and length of stay. Later hospital median age at ASO was associated with higher odds of mortality (odds ratio, 1.15 per day; 95% CI, 1.02-1.29; P=0.03), longer length of stay ( P<0.004), and higher cost ( P<0.001). Other hospital factors were not independently associated with the outcomes of interest. CONCLUSIONS There was significant variation in preoperative care between hospitals. Some potentially modifiable aspects of perioperative care (timing of ASO and septostomy) were significantly associated with mortality, length of stay, and cost. Further research on the perioperative care of neonates is necessary to determine whether modifying practice on the basis of the observed associations translates into improved outcomes.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.).,Leonard Davis Institute University of Pennsylvania, Philadelphia (M.L.O.).,Cardiovascular Outcomes, Quality, and Evaluative Research Center University of Pennsylvania, Philadelphia (M.L.O.)
| | - Andrew C Glatz
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania.,Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Lihai Song
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Heather M Griffis
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Marisa E Millenson
- Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, PA (M.L.O., A.C.G., L.S., H.M.G., M.E.M.)
| | - Matthew J Gillespie
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Yoav Dori
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Aaron G DeWitt
- Division of Cardiac Critical Care Medicine (A.G.D.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Christopher E Mascio
- Division of Cardiothoracic Surgery (C.E.M.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
| | - Jonathan J Rome
- Division of Cardiology (M.L.O., A.C.G., M.J.G., Y.D., J.J.R.), The Children's Hospital of Philadelphia and Perelman School of Medicine at the University of Pennsylvania
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19
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Dalal NN, Dzelebdzic S, Frank LH, Clauss SB, Mitchell SJ, Aljohani OA, Bradley-Hewitt T, Harahsheh AS. Recurrent Cardiology Evaluation for Innocent Heart Murmur: Echocardiogram Utilization. Clin Pediatr (Phila) 2018; 57:1436-1441. [PMID: 29993270 DOI: 10.1177/0009922818787280] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
We conducted a retrospective study to identify electrocardiogram (ECG) and echocardiogram utilization among patients presenting for a follow-up cardiology evaluation with innocent heart murmur between 2012 and 2014. The 2014 echocardiogram Appropriate Use Criteria was applied. We observed high rates of ordering ECGs and echocardiograms on follow-up visits (79% and 36%); only 1 patient had an appropriate indication for echocardiogram while the rest had rarely appropriate indication. Having had an ECG done did not affect echocardiogram ordering behavior. Older patient age was the only factor associated with a higher likelihood for ordering echocardiograms on follow-up visit (odds ratio = 1.016, P = .021). In this small sample study, we noticed high rates of test utilization and low-probability utilization of echocardiogram in the recurrent evaluation of children with innocent heart murmur. A larger, multicenter prospective study to investigate patterns and drivers of test utilization in children with innocent heart murmur presenting for a follow-up cardiology visit is needed.
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Affiliation(s)
- Nupur N Dalal
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | | | - Lowell H Frank
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Sarah B Clauss
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | | | - Othman A Aljohani
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Tyler Bradley-Hewitt
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
| | - Ashraf S Harahsheh
- 1 Children's National Health System, Washington, DC, USA.,2 The George Washington University, Washington, DC, USA
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20
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O'Byrne ML, Kennedy KF, Rome JJ, Glatz AC. Variation in practice patterns in device closure of atrial septal defects and patent ductus arteriosus: An analysis of data from the IMproving Pediatric and Adult Congenital Treatment (IMPACT) registry. Am Heart J 2018; 196:119-130. [PMID: 29421004 DOI: 10.1016/j.ahj.2017.10.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 10/24/2017] [Indexed: 11/16/2022]
Abstract
Practice variation is a potentially important measure of healthcare quality. The IMPACT registry provides a representative national sample with which to study practice variation in trans-catheter interventions for congenital heart disease. METHODS We studied cases for closure of atrial septal defect (ASD) and patent ductus arteriosus (PDA) in IMPACT between January 1, 2011, and September 30, 2015, using hierarchical multivariate models studying (1) the distribution of indications for closure and (2) in patients whose indication for closure was left (LVVO) or right ventricular volume overload (RVVO), the factors influencing probability of closure of a small defect (either in size or in terms of the magnitude of shunt). RESULTS Over the study period, 5233 PDA and 4459 ASD cases were performed at 77 hospitals. The indications for ASD closure were RVVO in 84% and stroke prevention in 13%. Indications for PDA closure were LVVO in 57%, endocarditis prevention in 36%, and pulmonary hypertension in 7%. There was statistically significant variability in indications between hospitals for PDA and ASD procedures (median rate ratio (MRR): 1.3 and 1.1; both P<.001). The proportion of cases for volume overload with a Qp:Qs <1.5:1 decreased with increasing PDA and ASD procedural volume (P=.04 and 0.05). For ASD, the proportion was higher at hospitals with a larger proportion of adult cases (P=.0007). There was significant variation in practice in the risk of closing PDA <2 mm for LVVO (MRR: 1.4, P<.001). CONCLUSION There is measurable variation in transcatheter closure of PDA and ASD. Further research is necessary to study whether this affects outcomes or resource utilization.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology, Children's National Health System and Department of Pediatrics, George Washington University School of Health Sciences, Washington, DC, USA.
| | - Kevin F Kennedy
- Mid America Heart Institute St. Luke's Health System, Kansas City, MO, USA
| | - Jonathan J Rome
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Andrew C Glatz
- Division of Cardiology, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA; Center for Pediatric Clinical Effectiveness, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, PA, USA
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21
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O’Byrne ML, Glatz AC, Gillespie MJ. Transcatheter device closure of atrial septal defects: more to think about than just closing the hole. Curr Opin Cardiol 2018; 33:108-116. [PMID: 29076870 PMCID: PMC6112166 DOI: 10.1097/hco.0000000000000476] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW To review current controversies in the transcatheter device closure of ostium secundum atrial septal defects (ASD). RECENT FINDINGS Transcatheter device closure of ASD (TC-ASD) has well established efficacy and safety. For most individual patients with suitable anatomy, TC-ASD is the preferred method for treating ASD. The availability of large multicenter data sets has made it possible to study practice patterns at a range of hospitals across the United States. These studies have revealed differences in practice that were not previously appreciated. Interpretation of the indications for TC-ASD, specifically the definition of right ventricular volume overload varies between hospitals. In response to concern about device erosion, an increasing proportion of patients are being referred for operative ASD closure. Over the last decade, the average age at which ASD closure occurs has decreased. These trends demonstrate previously underappreciated differences in opinion between cardiologists across the country and suggest that further research is necessary to address knowledge gaps limiting consistency of practice. SUMMARY As TC-ASD and congenital interventional cardiology mature as a field, studies of real-world practice provide increasingly valuable information about aspects of care in which there are disagreements about best practices and in which further research is necessary.
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Affiliation(s)
- Michael L O’Byrne
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
- Center for Pediatric Clinical Effectiveness and Cardiac Center Research Core, The Children’s Hospital of Philadelphia, Philadelphia PA
- Leonard Davis Institute, University of Pennsylvania, Philadelphia PA
| | - Andrew C Glatz
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
- Center for Pediatric Clinical Effectiveness and Cardiac Center Research Core, The Children’s Hospital of Philadelphia, Philadelphia PA
| | - Matthew J Gillespie
- Division of Cardiology The Children’s Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania Philadelphia, Philadelphia PA
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