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Tchou MJ, Hall M, Markham JL, Stephens JR, Steiner MJ, McCoy E, Aronson PL, Shah SS, Molloy MJ, Cotter JM. Changing patterns of routine laboratory testing over time at children's hospitals. J Hosp Med 2024; 19:671-679. [PMID: 38643414 PMCID: PMC11296890 DOI: 10.1002/jhm.13372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/19/2024] [Accepted: 04/09/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Research into low-value routine testing at children's hospitals has not consistently evaluated changing patterns of testing over time. OBJECTIVES To identify changes in routine laboratory testing rates at children's hospitals over ten years and the association with patient outcomes. DESIGN, SETTINGS, AND PARTICIPANTS We performed a multi-center, retrospective cohort study of children aged 0-18 hospitalized with common, lower-severity diagnoses at 28 children's hospitals in the Pediatric Health Information Systems database. MAIN OUTCOMES AND MEASURES We calculated average annual testing rates for complete blood counts, electrolytes, and inflammatory markers between 2010 and 2019 for each hospital. A >2% average testing rate change per year was defined as clinically meaningful and used to separate hospitals into groups: increasing, decreasing, and unchanged testing rates. Groups were compared for differences in length of stay, cost, and 30-day readmission or ED revisit, adjusted for demographics and case mix index. RESULTS Our study included 576,572 encounters for common, low-severity diagnoses. Individual hospital testing rates in each year of the study varied from 0.3 to 1.4 tests per patient day. The average yearly change in hospital-specific testing rates ranged from -6% to +7%. Four hospitals remained in the lowest quartile of testing and two in the highest quartile throughout all 10 years of the study. We grouped hospitals with increasing (8), decreasing (n = 5), and unchanged (n = 15) testing rates. No difference was found across subgroups in costs, length of stay, 30-day ED revisit, or readmission rates. Comparing resource utilization trends over time provides important insights into achievable rates of testing reduction.
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Affiliation(s)
- Michael J. Tchou
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Matt Hall
- Children’s Hospital Association, Lenexa, Kansas, USA
| | - Jessica L. Markham
- Department of Pediatrics, Children’s Mercy Kansas City and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - John R. Stephens
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Michael J. Steiner
- North Carolina Children’s Hospital and School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Elisha McCoy
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of General Pediatrics, Le Bonheur Children’s Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Paul L. Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Samir S. Shah
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Matthew J. Molloy
- Cincinnati Children’s Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jillian M. Cotter
- Department of Pediatrics, Section of Hospital Medicine, University of Colorado-Anschutz Medical Center and Children’s Hospital Colorado, Aurora, Colorado, USA
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Raschein TS, Lammers S, Nickel A, Louie JP, Bergmann KR. Racial and Ethnic Differences in Hospital Admission and Diagnostic Evaluation for Febrile Seizures in the Emergency Department. J Pediatr 2024; 269:113960. [PMID: 38369236 DOI: 10.1016/j.jpeds.2024.113960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/25/2024] [Accepted: 02/13/2024] [Indexed: 02/20/2024]
Abstract
OBJECTIVE To examine differences in hospital admission and diagnostic evaluation for febrile seizure by race and ethnicity. STUDY DESIGN We conducted a cross-sectional study among children 6 months to 6 years with simple or complex febrile seizure between January 1, 2016, and December 31, 2021, using data from the Pediatric Health Information System. The primary outcome was hospital admission. Secondary outcomes included the proportion of encounters with neuroimaging or lumbar puncture. We used mixed-effects logistic regression model with random intercept for hospital and patient to estimate the association between outcomes and race and ethnicity after adjusting for covariates, including seizure type. RESULTS In total, 94 884 encounters were included. Most encounters occurred among children of non-Hispanic White (37.0%), Black (23.9%), and Hispanic/Latino (24.6%) race and ethnicity. Black and Hispanic/Latino children had 29% (aOR 0.71; 95% CI 0.66-0.75) and 26% (aOR 0.74; 95% CI 0.69-0.80) lower odds of hospital admission compared with non-Hispanic White children, respectively. Black and Hispanic/Latino children had 21% (aOR 0.79; 95% CI 0.73-0.86) and 22% (aOR 0.78; 95% CI 0.71-0.85) lower adjusted odds of neuroimaging compared with non-Hispanic White children. For complex febrile seizure, the adjusted odds of lumbar puncture was significantly greater among Asian children (aOR 2.12; 95% CI 1.19-3.77) compared with non-Hispanic White children. There were no racial differences in the odds of lumbar puncture for simple febrile seizure. CONCLUSIONS Compared with non-Hispanic White children, Black and Hispanic/Latino children with febrile seizures are less likely to be hospitalized or receive neuroimaging.
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Affiliation(s)
- Taryn S Raschein
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Shea Lammers
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN
| | - Amanda Nickel
- Department of Research and Sponsored Programs, Children's Minnesota, Minneapolis, MN
| | - Jeffrey P Louie
- Division of Emergency Medicine, University of Minnesota Masonic Children's Hospital, Minneapolis, MN
| | - Kelly R Bergmann
- Department of Pediatric Emergency Medicine, Children's Minnesota, Minneapolis, MN.
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Rudloff J, Lendrum E, Semenova O, Lipshaw MJ, Valentino C. The Success of Resident-Associated Lumbar Punctures at a Large, Single-Center Children's Hospital. Pediatr Emerg Care 2023; 39:432-435. [PMID: 36728895 DOI: 10.1097/pec.0000000000002884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES The frequency of lumbar punctures (LPs) has declined across US children's hospitals over the past decade, potentially decreasing procedural learning opportunities for pediatric resident trainees. Our study sought to determine whether the proportion of successful LPs performed by our pediatric residents has significantly changed over time. METHODS This study is a single-center retrospective study to evaluate our pediatric resident LP success. We evaluated our primary outcome, proportion of overall LP success over time, using linear regression. We similarly used linear regression for proportion of successful resident-associated LPs over time. We calculated the median number of LPs of all pediatric residents during the study period. RESULTS We analyzed 3143 LPs from April 2012 to December 2019. Both the overall number of LPs performed and the proportion of LPs that were successful have not significantly changed over an 8-year period ( P > 0.05, P > 0.05). Similarly, the number of our resident-associated LPs and the proportion of successful resident-associated LPs have not changed over the study period ( P > 0.05, P > 0.05). Our pediatric residents performed a median of 3 LPs (interquartile range: 2-4) in the pediatric emergency department (PED) over residency. CONCLUSIONS Despite national trends showing decreased LP rates at pediatric hospitals, we demonstrated stable proportions of LPs and success by our pediatric residents. Pediatric residents perform a relatively low number of LPs in the PED setting alone. Future research is needed to demonstrate whether these overall low numbers in the PED translate to procedural competency after residency graduation.
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Affiliation(s)
- James Rudloff
- From the Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Elizabeth Lendrum
- From the Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Olga Semenova
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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McBride M, Williman J, Best E, Walls T, Sadarangani M, Grant CC, Martin NG. The epidemiology of aseptic meningitis in New Zealand children from 1991 to 2020. J Paediatr Child Health 2022; 58:1980-1989. [PMID: 35861029 PMCID: PMC9796418 DOI: 10.1111/jpc.16131] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/19/2022] [Accepted: 07/06/2022] [Indexed: 01/01/2023]
Abstract
AIM Aseptic meningitis, including culture negative and viral meningitis, contributes a significant health-care burden, including unnecessary antibiotic use and hospitalisation to treat possible bacterial meningitis. This study analysed aseptic meningitis hospitalisations in New Zealand (NZ) children over 29 years. METHODS In this population-based study, aseptic meningitis hospitalisations in NZ children <15 years old were analysed from 1991 to 2020. Incident rate ratios were calculated using Poisson regression models. Variations in hospitalisations by age, year, sex, ethnicity, geographical region and socio-economic deprivation were analysed. RESULTS There were 5142 paediatric aseptic meningitis hospitalisations from 1991 to 2020. Most were unspecified viral meningitis (64%), followed by enterovirus (29%). Hospitalisation rates varied annually with a median of 18.4/100 000 children including a peak in 2001 of 56.4/100 000 (51.7-61.6). From 2002 to 2019, rates increased by 8.4%/year (7.2-9.5%) in infants <90 days old but decreased in all other age groups. In 2020, a reduction in hospitalisations to 9.6/100 000 (7.9-11.8) occurred, and in infants <90 days old were 0.37 times expected. Hospitalisations were 1.50 times (1.49-1.68) higher in males than females; higher in children of Māori (P < 0.001) and Pacific (P < 0.001) versus European ethnicity; and higher for children living in the most (2.44 times, (2.16-2.75)) versus least deprived households; and in northern versus southern NZ. CONCLUSIONS Aseptic meningitis hospitalisations increased in young infants during 29 years of surveillance, apart from 2020 when admissions reduced during the COVID-19 pandemic. In contrast, hospitalisations decreased in children aged >1 year. Further investigation into reasons for higher admissions by ethnic group, geographical location and increased deprivation are required.
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Affiliation(s)
- Michelia McBride
- Department of PaediatricsUniversity of Otago ChristchurchChristchurchNew Zealand
| | - Jonathan Williman
- Department of Population HealthUniversity of Otago ChristchurchChristchurchNew Zealand
| | - Emma Best
- Department of Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand,Department of Paediatric Infectious DiseasesStarship Children's HospitalAucklandNew Zealand
| | - Tony Walls
- Department of PaediatricsUniversity of Otago ChristchurchChristchurchNew Zealand
| | - Manish Sadarangani
- Vaccine Evaluation CenterBC Children's Hospital Research InstituteVancouverBritish ColumbiaCanada,Department of PediatricsUniversity of British ColumbiaVancouverBritish ColumbiaCanada
| | - Cameron C Grant
- Department of Paediatrics: Child and Youth HealthUniversity of AucklandAucklandNew Zealand
| | - Natalie G Martin
- Department of PaediatricsUniversity of Otago ChristchurchChristchurchNew Zealand
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Raghavan VR, Porter JJ, Neuman MI, Lyons TW. Trends in Management of Simple Febrile Seizures at US Children's Hospitals. Pediatrics 2021; 148:peds.2021-051517. [PMID: 34670823 DOI: 10.1542/peds.2021-051517] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to measure trends in evaluation and management of children with simple febrile seizures (SFSs) before and after the American Academy of Pediatrics updated guidelines published in 2011. METHODS In this retrospective, cross-sectional analysis, we used the Pediatric Health Information System database comprising 49 tertiary care pediatric hospitals in the United States from 2005 to 2019. We included children aged 6 to 60 months with an emergency department visit for first SFS identified using codes from the International Classification of Diseases, Ninth Revision, and International Classification of Diseases 10th Revision. RESULTS We identified 142 121 children (median age 21 months, 42.4% female) with an emergency department visit for SFS. A total of 49 668 (35.0%) children presented before and 92 453 (65.1%) after the guideline. The rate of lumbar puncture for all ages declined from 11.6% (95% confidence interval [CI], 10.8% to 12.4%) in 2005 to 0.6% (95% CI, 0.5% to 0.8%) in 2019 (P < .001). Similar reductions were noted in rates of head computed tomography (10.6% to 1.6%; P < .001), complete blood cell count (38.8% to 10.9%; P < .001), hospital admission (19.2% to 5.2%; P < .001), and mean costs ($1523 to $601; P < .001). Reductions in all outcomes began before, and continued after, the publication of the American Academy of Pediatrics guideline. There was no significant change in delayed diagnosis of bacterial meningitis (preperiod 2 of 49 668 [0.0040%; 95% CI, 0.00049% to 0.015%], postperiod 3 of 92 453 [0.0032%; 95% CI, 0.00066% to 0.0094%]; P = .99). CONCLUSIONS Diagnostic testing, hospital admission, and costs decreased over the study period, without a concomitant increase in delayed diagnosis of bacterial meningitis. These data suggest most children with SFSs can be safely managed without lumber puncture or other diagnostic testing.
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Affiliation(s)
- Vidya R Raghavan
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John J Porter
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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Emergence of Parechovirus A3 as the Leading Cause of Central Nervous System Infection, Surpassing Any Single Enterovirus Type, in Children in Kansas City, Missouri, USA, from 2007 to 2016. J Clin Microbiol 2021; 59:JCM.02935-20. [PMID: 33692140 DOI: 10.1128/jcm.02935-20] [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] [Received: 12/02/2020] [Accepted: 03/05/2021] [Indexed: 12/14/2022] Open
Abstract
Picornaviruses, including Enterovirus species A to D (EV) and Parechovirus species A (PeV-A), are the leading reported causes of pediatric central nervous system infections in the United States. We investigated the molecular epidemiology of EV and PeV-A over 10 years in cerebrospinal fluid (CSF) collected from children seen at Children's Mercy-Kansas City (CMKC) from 2007 through 2016. The overall prevalence for EV was 16% (862/5,362) and 7% (271/4,016) for PeV. Among all picornavirus CSF detections, EV was 76%, and PeV-A was 24%. Multiple EV types cocirculated each year, with a total of 31 EV types detected in the 10-year period; the majority belonged to EV-B species (96%). Two PeV-A types were detected; PeV-A3 was the dominant PeV-A type (95%). The top five picornaviruses (PeV-A3, 26%; E30, 11%; E6, 10%; E18, 9%; E9, 7%) in the CSF of infants accounted for two-thirds of all detections, and PeV-A3 was the leading picornavirus detected. Routine testing and reporting of PeV-A in addition to EV, especially in children under 6 months old with acute febrile illnesses, could reduce hospital stays and antibiotic usage.
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Declines in the Number of Lumbar Punctures Performed at United States Children's Hospitals, 2009-2019. J Pediatr 2021; 231:87-93.e1. [PMID: 33080276 DOI: 10.1016/j.jpeds.2020.10.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/22/2020] [Accepted: 10/15/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To evaluate trends in lumbar puncture (LP) performance among US children's hospitals to assess how these trends may impact pediatric resident trainee exposure to LP. STUDY DESIGN We quantified LPs for emergency department (ED) and inpatient encounters at 29 US children's hospitals from 2009 to 2019. LP was defined by either a LP procedure code or cerebrospinal fluid culture billing code. Temporal trends and hospital variation in LP were assessed using logistic regression analysis. RESULTS A total of 215 030 LPs were performed during the study period (0.8% of all encounters). Twenty six thousand and five hundred twenty three and 16 696 LPs were performed in the 2009 and 2018 academic years, respectively (overall 37.1% reduction, per-year OR, 0.935; 95% CI, 0.922-0.948; P < .001), and the rate of LP decreased from 10.9 per 1000 hospital encounters to 6.0 per 1000 hospital encounters over the same period. CONCLUSIONS LP rates have declined across US children's hospitals over the past decade, potentially resulting in reduced clinical exposure for pediatric resident trainees. Improved procedural simulation during residency may augment the clinical experience.
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Garcia PCR, Barcelos ALM, Tonial CT, Fiori HH, Einloft PR, Costa CAD, Portela JL, Bruno F, Branco RG. Accuracy of cerebrospinal fluid ferritin for purulent meningitis. Arch Dis Child 2021; 106:286-289. [PMID: 32111595 DOI: 10.1136/archdischild-2019-317960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To evaluate the use of cerebrospinal fluid (CSF) ferritin levels in the diagnosis of purulent meningitis (PM). METHOD We studied 81 children between 28 days and 12 years of age who presented with clinical suspicion of meningitis to the emergency department. CSF ferritin levels were measured and compared between diagnostic groups (PM, aseptic meningitis (AM) and no meningitis). RESULTS The median age was 24 (IQR 8-69) months. There were 32 patients with AM (39%), 23 with PM (28%) and 26 with no meningitis (32%). Median CSF ferritin was 4.2 ng/mL (IQR 3.0-6.5), 52.9 ng/mL (IQR 30.7-103 ng/mL) and 2.4 ng/mL (IQR 2-4), respectively. CSF ferritin was higher in children with PM compared with AM (p<0.001) or no meningitis (p<0.001). There was no difference between AM and no meningitis. CONCLUSION CSF ferritin may be a useful biomarker to discriminate PM in children with clinical symptoms of this disease.
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Affiliation(s)
- Pedro Celiny Ramos Garcia
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Cristian Tedesco Tonial
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Humberto Holmer Fiori
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Paulo Roberto Einloft
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Caroline Abud Drumond Costa
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
| | | | - Francisco Bruno
- Postgraduate Program in Pediatrics and Child Health, Pontificia Universidade Catolica do Rio Grande do Sul, Porto Alegre, Brazil
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Kohil A, Jemmieh S, Smatti MK, Yassine HM. Viral meningitis: an overview. Arch Virol 2021; 166:335-345. [PMID: 33392820 PMCID: PMC7779091 DOI: 10.1007/s00705-020-04891-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Accepted: 10/04/2020] [Indexed: 12/14/2022]
Abstract
Meningitis is a serious condition that affects the central nervous system. It is an inflammation of the meninges, which is the membrane that surrounds both the brain and the spinal cord. Meningitis can be caused by bacterial, viral, or fungal infections. Many viruses, such as enteroviruses, herpesviruses, and influenza viruses, can cause this neurological disorder. However, enteroviruses have been found to be the underlying cause of most viral meningitis cases worldwide. With few exceptions, the clinical manifestations and symptoms associated with viral meningitis are similar for the different causative agents, which makes it difficult to diagnose the disease at early stages. The pathogenesis of viral meningitis is not clearly defined, and more studies are needed to improve the health care of patients in terms of early diagnosis and management. This review article discusses the most common causative agents, epidemiology, clinical features, diagnosis, and pathogenesis of viral meningitis.
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Affiliation(s)
- Amira Kohil
- Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Sara Jemmieh
- Department of Biomedical Sciences, College of Health Sciences, QU Health, Qatar University, Doha, Qatar
| | - Maria K Smatti
- Biomedical Research Center, Qatar University, Doha, Qatar
| | - Hadi M Yassine
- Biomedical Research Center, Qatar University, Doha, Qatar.
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The Prevalence of Viruses in the Cerebrospinal Fluid of Children with Aseptic Meningitis in Shiraz, Iran. ARCHIVES OF CLINICAL INFECTIOUS DISEASES 2020. [DOI: 10.5812/archcid.100850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: The current study aimed to evaluate the causative agents of viral meningitis through real-time PCR among children with aseptic meningitis. Methods: Children aged 1 month to 16 years with suspected viral meningitis were enrolled in this study (March 2014-February 2015). Cerebrospinal fluid samples were analyzed by real-time PCR for detection of enterovirus, mumps, measles, adenovirus, EBV, CMV, VZV, hhv 6, and rubella viruses. Demographic information, laboratory data, and clinical presentations of patients were also collected. Results: Of 56 patients suspected to viral meningitis, 21 (38.9 %) had a positive PCR result. Enterovirus (42.85%) and mumps (38.1%) were the most prevalent viruses, and VZV and measles were not detected. Three children were coinfected with enterovirus/hhv6, enterovirus/EBV, and mump/adenovirus. Fever, headache, and nausea/vomiting were the most common symptoms in children. The rates of symptoms were not statistically significant among children with positive and negative PCR tests. Conclusions: In the present study Enterovirus and mumps viruses were the most common causes of viral meningitis in children. PCR, as a rapid test for the diagnosis of viral meningitis, can be used to decrease hospitalization length.
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Zhao JL, Hua CZ, Xie YP, Pan YX, Hu BF, Wang WJ, He X. Diagnostic Yield of Multiplex PCR Method in Cerebrospinal Fluid for the Diagnosis of Purulent Meningitis in Children. J PEDIAT INF DIS-GER 2020. [DOI: 10.1055/s-0040-1719163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Abstract
Objective To evaluate the diagnostic yield of the multiplex polymerase chain reaction (PCR) method in cerebrospinal fluid (CSF) for the diagnosis of purulent meningitis (PM) in children.
Methods PM was diagnosed according to the European Society for Clinical Microbiology and Infectious Diseases guideline (2016). Patients with PM between May 2015 and October 2018 were included. The multiplex PCR method was used to detect eight common identified bacteria in PM. Its sensitivity and specificity were compared with bacteria culture.
Results A total of 106 cases were enrolled. Pathogenic bacteria were identified in 27 (25.5%) cases by culture and in 37 (34.9%) cases by multiplex PCR assay. The top three bacteria were Streptococcus pneumoniae, Escherichia coli K1, and Streptococcus agalactiae. When using culture as the gold standard, the multiplex PCR assay showed a sensitivity of 100, 88.9, and 75.0% for S. agalactiae, S. pneumoniae, and E. coli K1, respectively, and a specificity of more than 91.3% for all three bacteria. For detectable bacteria, the positive rate of the multiplex PCR assay (36.6%, 37/101) was significantly higher than that of the bacteria culture (21.8%, 22/101). When combining the two methods, etiology was identified in 42.5% (45/106) of the patients.
Conclusion Streptococcus pneumoniae, E. coli K1, and S. agalactiae were the predominant pathogens causing pediatric PM. As a rapid method with high sensitivity and specificity, the multiplex PCR assay in CSF could be used as an adjunctive approach with bacteria culture for the pathogen identification of PM.
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Affiliation(s)
- Jing-Li Zhao
- Department of Infectious Diseases, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
- Department of Nephrology, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Chun-Zhen Hua
- Department of Infectious Diseases, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yong-Ping Xie
- Department of Infectious Diseases, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Yan-Xiang Pan
- Department of Clinical Laboratory Center, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Bo-Fei Hu
- Department of Infectious Diseases, National Clinical Research Center for Child Health, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, P.R. China
| | - Wei-Jian Wang
- Department of Research and Development, Health Gene Technologies Co., Ltd., Ningbo, Zhejiang, P.R. China
| | - Xiu He
- Department of Marketing,r Health Gene Technologies Co., Ltd., Ningbo, Zhejiang, P.R. China
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Freer S, House DT, Hallman MG. Viral Meningitis: A Pediatric Case Study. Adv Emerg Nurs J 2020; 42:254-261. [PMID: 33105178 DOI: 10.1097/tme.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Meningitis is a significant viral, bacterial, or fungal infection of the meninges that cover and protect the brain and the spinal cord. Symptoms of meningitis may present rapidly or develop gradually over a period of days, manifesting with common prodromal flu-like symptoms of headache, photophobia, fever, nuchal rigidity, myalgias, and fatigue. Character and significance of symptoms vary by patient age. Symptoms of infection may improve spontaneously or worsen, becoming potentially lethal. Early recognition and treatment of meningitis are crucial to prevent morbidity and mortality. The case reviewed in this article focuses on viral meningitis in a pediatric patient that may be unrecognized or underreported because of indistinct symptoms. Epidemiology, pathophysiology, presentation, assessment techniques, diagnostics, clinical management, and health promotion relevant to viral meningitis are presented.
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Affiliation(s)
- Sarah Freer
- University of Alabama at Birmingham School of Nursing
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Fulton BD, Proudman DG, Sample HA, Gelfand JM, Chiu CY, DeRisi JL, Wilson MR. Exploratory analysis of the potential for advanced diagnostic testing to reduce healthcare expenditures of patients hospitalized with meningitis or encephalitis. PLoS One 2020; 15:e0226895. [PMID: 31940319 PMCID: PMC6961903 DOI: 10.1371/journal.pone.0226895] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 12/08/2019] [Indexed: 11/19/2022] Open
Abstract
Objective To estimate healthcare expenditures that could be impacted by advanced diagnostic testing for patients hospitalized with meningitis or encephalitis Methods Patients hospitalized with meningitis (N = 23,933) or encephalitis (N = 7,858) in the U.S. were identified in the 2010–2014 Truven Health MarketScan Commercial Claims and Encounters Database using ICD-9-CM diagnostic codes. The database included an average of 40.8 million commercially insured enrollees under age 65 per year. Clinical, demographic and healthcare utilization criteria were used to identify patient subgroups early in their episode who were at risk to have high inpatient expenditures. Healthcare expenditures of patients within each subgroup were bifurcated: those expenditures that remained five days after the patient could be classified into the subgroup versus those that had occurred previously. Results The hospitalization episode rate per 100,000 enrollee-years for meningitis was 13.0 (95% CI: 12.9–13.2) and for encephalitis was 4.3 (95% CI: 4.2–4.4), with mean inpatient expenditures of $36,891 (SD = $92,636) and $60,181 (SD = $130,276), respectively. If advanced diagnostic testing had been administered on the day that a patient could be classified into a subgroup, then a test with a five-day turnaround time could impact the following mean inpatient expenditures that remained by subgroup for patients with meningitis or encephalitis, respectively: had a neurosurgical procedure ($83,337 and $56,020), had an ICU stay ($34,221 and $46,051), had HIV-1 infection or a previous organ transplant ($37,702 and $62,222), were age <1 year ($35,371 and $52,812), or had a hospital length of stay >2 days ($18,325 and $30,244). Discussion Inpatient expenditures for patients hospitalized with meningitis or encephalitis were substantial and varied widely. Patient subgroups who had high healthcare expenditures could be identified early in their stay, raising the potential for advanced diagnostic testing to lower these expenditures.
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Affiliation(s)
- Brent D. Fulton
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
- * E-mail:
| | - David G. Proudman
- School of Public Health, University of California, Berkeley, Berkeley, California, United States of America
| | - Hannah A. Sample
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, California, United States of America
| | - Jeffrey M. Gelfand
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, United States of America
| | - Charles Y. Chiu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, California, United States of America
- Department of Medicine, University of California, San Francisco, San Francisco, California, United States of America
- UCSF-Abbott Viral Diagnostics and Discovery Center, San Francisco, California, United States of America
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, California, United States of America
- Chan Zuckerberg Biohub, San Francisco, California, United States of America
| | - Michael R. Wilson
- Department of Neurology, Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, California, United States of America
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Rees CA, Cruz AT, Freedman SB, Mahajan P, Uspal NG, Okada P, Aronson PL, Thompson AD, Ishimine PT, Schmidt SM, Kuppermann N, Nigrovic LE. Application of the Bacterial Meningitis Score for Infants Aged 0 to 60 Days. J Pediatric Infect Dis Soc 2019; 8:559-562. [PMID: 30535235 DOI: 10.1093/jpids/piy126] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 11/11/2018] [Indexed: 11/14/2022]
Abstract
In 4292 infants aged ≤60 days with cerebrospinal fluid (CSF) pleocytosis, the bacterial meningitis score had excellent sensitivity (121 of 121 [100.0%] [95% confidence interval, 96.5%-100.0%]) but low specificity (66 of 4171 [1.6%] [95% confidence interval, 1.3%-2.0%]) and therefore should not be applied clinically to infants in this age group.
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Affiliation(s)
- Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts
| | - Andrea T Cruz
- Department of Pediatrics, Sections of Emergency Medicine and Infectious Diseases, Baylor College of Medicine, Houston, Texas
| | - Stephen B Freedman
- Department of Pediatrics, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital and Cumming School of Medicine, University of Calgary, Canada
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics, Mott Children's Hospital, University of Michigan, Ann Arbor
| | - Neil G Uspal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Dallas
| | - Pamela Okada
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Paul L Aronson
- Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amy D Thompson
- Departments of Pediatrics and Emergency Medicine, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware
| | - Paul T Ishimine
- Departments of Emergency Medicine and Pediatrics, Rady Children's Hospital, University of California, San Diego School of Medicine, IL
| | - Suzanne M Schmidt
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, IL
| | - Nathan Kuppermann
- University of California Davis Health and the University of California Davis School of Medicine, Sacramento
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Massachusetts
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Diagnostic Practices for Suspected Community-Acquired Central Nervous System Infection in the Post-Conjugate Vaccine Era. Pediatr Emerg Care 2019; 35:774-776. [PMID: 28463942 DOI: 10.1097/pec.0000000000001147] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate diagnostic practices for suspected community-acquired central nervous system (CNS) infection in an urban pediatric population. METHODS This is an observational, retrospective single-center review of cerebrospinal fluid (CSF) studies in children, 1 month to 21 years old, evaluated for suspected CNS infection from 2004 to 2014. Cases of suspected nosocomial meningitis were excluded. The frequency of N-methyl-D-aspartate receptor antibody (NMDAR ab) encephalitis was analyzed from 2010 to 2014. RESULTS A total of 940 unique patient visits with CSF studies were included in the final analysis. There were 940 bacterial cultures sent; 4 (0.42%) grew suspected CSF bacterial pathogens, and 18 (1.9%) grew organisms that were suspected contaminants. Bacterial pathogens included late-onset group B Streptococcus in 3 infants younger than 3 months and Streptococcus pneumoniae in an unvaccinated 9-year-old child. Viral CNS infection was 7.5 times more frequent than bacterial infection. Enterovirus was the only virus isolated. Five cases positive for NMDAR ab were identified since 2010. CONCLUSIONS Bacterial studies were performed more frequently than viral and other studies. Cerebrospinal fluid bacterial culture was nearly 5 times more likely to yield a contaminant than a pathogen. The frequency of viral infection was likely underestimated as only 20% were tested, mainly by culture, which is suboptimal. These data suggest diagnostic practices for the evaluation of suspected community-acquired CNS infections in children need to be modified to reflect current epidemiology and highlight the need for greater accessibility to polymerase chain reaction for viral diagnostics. Furthermore, NMDAR ab-mediated encephalitis should be considered early in children presenting with suggestive symptoms.
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Du B, Hua C, Xia Y, Li J, Xie Y, Tao Y, Cao Q, Mo X. Evaluation of the BioFire FilmArray meningitis/encephalitis panel for the detection of bacteria and yeast in Chinese children. ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:437. [PMID: 31700873 DOI: 10.21037/atm.2019.08.103] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Background Meningitis and encephalitis are life-threatening syndromes with high morbidity and mortality in children. Due to limitations of traditional laboratory approaches in etiological diagnosis, the rate of misdiagnoses is unacceptably high. Methods We retrospectively compared the potential clinical impact of the FilmArray meningitis/encephalitis (ME) panel vs. conventional cerebrospinal fluid (CSF) culture in children with central nervous system (CNS) infections. Sixty-eight pediatric patients (<18 years of age) with an initial diagnosis of meningitis or encephalitis were enrolled at 2 children's hospital from January to October 2017. Results Fifteen specimens were found to be positive after CSF culture, with a positive rate of 22.1% (15/68). For the FilmArray ME panel, 26 bacteria and fungi from 25 samples were detected, and the positive rate was 36.8% (25/68). The FilmArray ME panel identified 14 pathogens in previously pathogen-negative patients. Conclusions This study demonstrated the capability of the FilmArray ME panel in the diagnosis of bacterial and fungal meningitis and therefore its potential use in facilitating enhanced patient care.
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Affiliation(s)
- Bailu Du
- Department of Infectious Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Chunzhen Hua
- Department of Infectious Diseases, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Yijun Xia
- Department of Medical Affairs, bioMérieux (Shanghai) Company Limited, Shanghai 201315, China
| | - Jin Li
- Department of Infectious Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yongping Xie
- Department of Infectious Diseases, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Yue Tao
- The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Qing Cao
- Department of Infectious Diseases, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Xi Mo
- The Laboratory of Pediatric Infectious Diseases, Pediatric Translational Medicine Institute, Shanghai Children's Medical Center, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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Zhang Y, Sun X, Wu J, Sun A. Value of MRI enhanced FLAIR sequence examination combined with CSF TNF-α detection in the early diagnosis of neonatal purulent meningitis. Exp Ther Med 2019; 17:3124-3128. [PMID: 30936984 PMCID: PMC6434275 DOI: 10.3892/etm.2019.7305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 01/23/2019] [Indexed: 11/16/2022] Open
Abstract
This study aimed to investigate the value of MRI enhanced fluid-attenuated inversion recovery (FLAIR) combined with TNF-α in cerebrospinal fluid in the diagnosis of neonatal purulent meningitis. Fifty neonates with purulent meningitis were randomly selected in the purulency group, 50 patients with viral meningitis (VM) in the virus group and 50 neonates without purulent meningitis in the no meningitis group. All neonates were selected from April 2015 to May 2018 in Women and Children's Hospital (Linyi, China). Clinical baseline data of the three groups were compared, and logistic regression analysis was conducted to analyze the risk factors of the disease. The risk factors of neonatal purulent meningitis include white bold cell count, TNF-α, encephaledema, encephaledema combined with abnormal EEG, erythrocyte sedimentation rate and FLAIR sequential apparent diffusion coefficient (ADC). TNF-α in cerebrospinal fluid combined with FLAIR sequential ADC obtained higher sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy and AUC than single TNF-α in cerebrospinal fluid examination or single FLAIR sequence. MRI enhanced FLAIR sequence scan combined with TNF-α in cerebrospinal fluid has the highest rate in early diagnosis of neonatal purulent meningitis, and it is worthy of clinical promotion.
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Affiliation(s)
- Yanli Zhang
- Department of Pediatrics, Linyi Women and Children's Hospital, Linyi, Shandong 276014, P.R. China
| | - Xiaolin Sun
- Department of Neonatology, Linyi Women and Children's Hospital, Linyi, Shandong 276014, P.R. China
| | - Jun Wu
- Department of Radiology, Linyi Women and Children's Hospital, Linyi, Shandong 276014, P.R. China
| | - Airong Sun
- Department of Neonatology, Linyi Women and Children's Hospital, Linyi, Shandong 276014, P.R. China
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18
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Epidemiology of Meningitis and Encephalitis in Infants and Children in the United States, 2011-2014. Pediatr Infect Dis J 2019; 38:37-41. [PMID: 30531527 DOI: 10.1097/inf.0000000000002081] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Large epidemiologic studies evaluating the etiologies, management decisions and outcomes of infants and children with meningitis and encephalitis in the United States are lacking. METHODS Children 0-17 years of age with meningitis or encephalitis as assessed by International Classification of Diseases, Ninth Revision, codes available in the Premier Healthcare Database during 2011-2014 were analyzed. RESULTS Six thousand six hundred sixty-five patients with meningitis or encephalitis were identified; 3030 (45.5%) were younger than 1 year of age, 295 (4.4%) were 1-2 years of age, 1460 (21.9%) were 3-9 years of age, and 1880 (28.2%) were 10-17 years of age. Etiologies included enterovirus (58.4%), unknown (23.7%), bacterial (13.0%), noninfectious (3.1%), herpes simplex virus (1.5%), other viruses (0.7%), arboviruses (0.5%) and fungal (0.04%). The majority of patients were male [3847 (57.7%)] and healthy [6094 (91.4%)] with no reported underlying conditions. Most underwent a lumbar puncture in the emergency department [5363 (80%)] and were admitted to the hospital [5363 (83.1%)]. Antibiotic therapy was frequent (92.2%) with children younger than 1 year of age with the highest rates (97.7%). Antiviral therapy was less common (31.1%). Only 539 (8.1%) of 6665 of patients received steroids. Early administration of adjunctive steroids was not associated with a reduction in mortality (P = 0.266). The overall median length of stay was 2 days. Overall mortality rate (0.5%) and readmission rates (<1%) was low for both groups. CONCLUSION Meningitis and encephalitis in infants and children in the United States are more commonly caused by viruses and are treated empirically with antibiotic therapy and antiviral therapy in a significant proportion of cases. Adjunctive steroids are used infrequently and are not associated with a benefit in mortality.
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Abstract
OBJECTIVES Enterovirus is the most common cause of aseptic meningitis in children. This study aimed at identifying baseline variables associated with a positive cerebrospinal fluid (CSF) Enterovirus polymerase chain reaction (PCR) to aid clinicians in targeting patients who could be tested and treated as outpatients. METHODS We performed a retrospective review of children (2 months to 17 years old) admitted to the Children's Memorial Hermann Hospital in Houston, TX, between January 2005 and December 2010 with symptoms of meningitis, CSF white cell count of greater than 5 cells/mm, and a negative CSF Gram stain, who had a CSF Enterovirus PCR. RESULTS One hundred thirty-seven children were reviewed; median age was 4.7 (0.1-17.1) years, and 79 (58%) were male. Fifty patients (37%) had positive CSF Enterovirus PCR. Only 13 (15%) of the Enterovirus PCR-negative patients had an identifiable etiology. All patients were hospitalized. The mean hospital stay for patients with Enterovirus was 2.9 days; 88% received empiric antibiotics. Rates of antibiotic administration were not different between PCR-positive and PCR-negative groups (P > 0.05). All patients with Enterovirus had a favorable clinical outcome.A predictive model was created using 3 baseline variables independently associated with a positive Enterovirus PCR (P < 0.05): May to November presentation, CSF protein of less than 100 mg/dL, and absence of focal neurologic signs. The model classified patients into 2 risk categories for a positive Enterovirus PCR (low risk, 0% [0/17 patients]; high risk, 42% [50/120 patients]; P < 0.001). CONCLUSIONS Our predictive model can be used to identify children for whom Enterovirus PCR testing is warranted. Such testing could avoid unnecessary hospitalization and antibiotic administration.
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20
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Balada-Llasat JM, Rosenthal N, Hasbun R, Zimmer L, Bozzette S, Duff S, Chung J, Ginocchio CC. Cost of managing meningitis and encephalitis among infants and children in the United States. Diagn Microbiol Infect Dis 2018; 93:349-354. [PMID: 30442508 DOI: 10.1016/j.diagmicrobio.2018.10.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 10/15/2018] [Accepted: 10/16/2018] [Indexed: 10/28/2022]
Abstract
A retrospective cohort study design was used to assess the use and costs of diagnostic tests, medication, and total hospitalization costs for pediatric patients with suspected meningitis/encephalitis who received a lumbar puncture (LP) procedure. Related costs were calculated by timing of LP performed and infectious etiology for infants (<1 year) and children (1-17 years). A total of 3030 infants and 3635 children with suspected ME diagnosed between 2011 and 2014 were included in the study. The mean hospitalization cost for infants and children was $12,759 and $11,119, respectively, with medication and laboratory test costs of $834 and $1771 for infants and $825 and $855 for children, respectively. Total visit cost increased with delayed LP procedure, ICU stay, and if the etiology was viral (other than enterovirus or arbovirus) or bacterial. Higher diagnostic and treatment costs were associated with delayed LP procedure, etiologic agent, and ICU stay.
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Affiliation(s)
| | - Ning Rosenthal
- Premier Applied Sciences, Premier Healthcare Solutions Inc., Charlotte, NC
| | | | | | - Samuel Bozzette
- Premier Applied Sciences, Premier Healthcare Solutions Inc., Charlotte, NC; University of California, San Diego, CA
| | - Steven Duff
- Veritas Health Economics Consulting, Carlsbad, CA
| | - Jessica Chung
- Premier Applied Sciences, Premier Healthcare Solutions Inc., Charlotte, NC
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21
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Garcia S, Echevarri J, Arana-Arri E, Sota M, Benito J, Mintegi S. Outpatient management of children at low risk for bacterial meningitis. Emerg Med J 2018; 35:361-366. [PMID: 29563150 DOI: 10.1136/emermed-2017-206834] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 02/01/2018] [Accepted: 03/05/2018] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the outcome of children aged 2-14 years with cerebrospinal fluid (CSF) pleocytosis and at very low risk for bacterial meningitis managed as outpatients without antibiotics. METHODS Multicentre, prospective, observational study conducted at nine Spanish paediatric EDs. Patients were diagnosed with meningitis based on clinical suspicion of meningitis and CSF pleocytosis when evaluated in the ED. Children between 2 and 14 years of age with pleocytosis and very low-risk criteria for bacterial meningitis (well appearing, Bacterial Meningitis Score (BMS)=0, procalcitonin (PCT)<0.5 ng/mL and observation without deterioration for less than 24 hours in the ED) were treated as outpatients without antibiotics pending CSF cultures. The primary composite outcome was a final diagnosis of bacterial meningitis or return to the ED for clinical deterioration. RESULTS Of 182 children between 2 and 14 years old diagnosed with meningitis, 56 met the very low-risk criteria and 45 were managed as outpatients. None was diagnosed with bacterial meningitis or returned due to clinical deterioration. Another 31 patients with BMS=1 (due to a peripheral absolute neutrophil count (ANC)>10 000/mm3) and PCT <0.5 ng/mL were managed as outpatients, diagnosed with aseptic meningitis and did well. BMS using PCT had the same sensitivity but greater specificity than classic BMS. CONCLUSIONS This set of low-risk criteria appears safe for the outpatient management without antibiotics of children with CSF pleocytosis. Larger studies are needed to evaluate the predictive values of replacing peripheral ANC with PCT in the BMS.
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Affiliation(s)
- Silvia Garcia
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
| | - Janire Echevarri
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
| | - Eunate Arana-Arri
- Clinical Epidemiology Unit, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Mercedes Sota
- Microbiology Department, BioCruces Health Research Institute, Cruces University Hospital, Barakaldo, Spain
| | - Javier Benito
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
| | - Santiago Mintegi
- Pediatric Emergency Department, Cruces University Hospital, Barakaldo, Spain.,Department of Pediatrics, University of the Basque Country, Bilbao, Spain
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22
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Duff S, Hasbun R, Ginocchio CC, Balada-Llasat JM, Zimmer L, Bozzette SA. Economic analysis of rapid multiplex polymerase chain reaction testing for meningitis/encephalitis in pediatric patients. Future Microbiol 2018; 13:617-629. [PMID: 29316801 DOI: 10.2217/fmb-2017-0238] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AIM We assessed the possible economic impact of a rapid test in pediatric patients with suspected community-acquired meningitis/encephalitis. MATERIALS & METHODS Modeling simulated diagnosis, clinical decisions, resource use/costs of standard of care (SOC) and two cerebrospinal fluid testing strategies using FilmArray® (FA), a US FDA-cleared system that provides results in approximately 1 h. RESULTS Pathogens detected by FA caused approximately 75% of cases, 97% of which would be accurately diagnosed with FA. Mean cost/case ranged from $17,599 to $22,025. Syndromic testing is less expensive than SOC. Testing all suspected cases yielded greater savings ($3481/case) than testing only those with abnormal cerebrospinal fluid ($2157/case). CONCLUSION Greater economic benefits are achievable with syndromic testing of all cases, rather than SOC or targeted syndromic testing.
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Affiliation(s)
- Steve Duff
- Veritas Health Economics Consulting, Carlsbad, CA, USA
| | | | - Christine C Ginocchio
- bioMérieux, Durham, NC, USA.,BioFire Diagnostics, Salt Lake City, UT, USA.,Department of Pathology and Laboratory Medicine, Hofstra Northwell School of Medicine, Hempstead, NY, USA
| | | | | | - Samuel A Bozzette
- bioMérieux, Durham, NC, USA.,University of California, San Diego, CA, USA
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Hospital admissions for viral meningitis in children in England over five decades: a population-based observational study. THE LANCET. INFECTIOUS DISEASES 2016; 16:1279-1287. [DOI: 10.1016/s1473-3099(16)30201-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/19/2016] [Accepted: 06/13/2016] [Indexed: 11/18/2022]
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Messacar K, Breazeale G, Robinson CC, Dominguez SR. Potential clinical impact of the film array meningitis encephalitis panel in children with suspected central nervous system infections. Diagn Microbiol Infect Dis 2016; 86:118-20. [PMID: 27342782 DOI: 10.1016/j.diagmicrobio.2016.05.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Revised: 05/23/2016] [Accepted: 05/29/2016] [Indexed: 11/27/2022]
Abstract
The FilmArray Meningitis Encephalitis Panel, a multiplex PCR for testing of cerebrospinal fluid, was compared to conventional diagnostic methods in children with suspected central nervous system infections. The panel had comparable diagnostic yield (96% agreement) and improved time-to-diagnosis by 10.3 hours with potential for more judicious antimicrobial use, particularly acyclovir.
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Affiliation(s)
- Kevin Messacar
- University of Colorado/Children's Hospital Colorado Department of Pediatrics, Section of Infectious Diseases, Aurora, CO, USA; University of Colorado/Children's Hospital Colorado Department of Pediatrics, Section of Hospital Medicine, Aurora, CO, USA.
| | - Garrett Breazeale
- Children's Hospital Colorado, Department of Pathology and Laboratory Medicine, Aurora, CO, USA
| | - Christine C Robinson
- Children's Hospital Colorado, Department of Pathology and Laboratory Medicine, Aurora, CO, USA
| | - Samuel R Dominguez
- University of Colorado/Children's Hospital Colorado Department of Pediatrics, Section of Infectious Diseases, Aurora, CO, USA; Children's Hospital Colorado Department of Epidemiology, Aurora, CO, USA
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Mealing N, Hayen A, Newall AT. Assessing the impact of vaccination programmes on burden of disease: Underlying complexities and statistical methods. Vaccine 2016; 34:3022-3029. [PMID: 27156635 DOI: 10.1016/j.vaccine.2016.04.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2015] [Revised: 04/04/2016] [Accepted: 04/06/2016] [Indexed: 11/28/2022]
Abstract
It is important to assess the impact a vaccination programme has on the burden of disease after it is implemented. For example, this may reveal herd immunity effects or vaccine-induced shifts in the incidence of disease or in circulating strains or serotypes of the pathogen. In this article we summarise the key features of infectious diseases that need to be considered when trying to detect any changes in the burden of diseases at a population level as a result of vaccination efforts. We outline the challenges of using routine surveillance databases to monitor infectious diseases, such as the identification of diseased cases and the availability of vaccination status for cases. We highlight the complexities in modelling the underlying patterns in infectious disease rates (e.g. presence of autocorrelation) and discuss the main statistical methods that can be used to control for periodicity (e.g. seasonality) and autocorrelation when assessing the impact of vaccination programmes on burden of disease (e.g. cosinor terms, generalised additive models, autoregressive processes and moving averages). For some analyses, there may be multiple methods that can be used, but it is important for authors to justify the method chosen and discuss any limitations. We present a case study review of the statistical methods used in the literature to assess the rotavirus vaccination programme impact in Australia. The methods used varied and included generalised linear models and descriptive statistics. Not all studies accounted for autocorrelation and seasonality, which can have a major influence on results. We recommend that future analyses consider the strength and weakness of alternative statistical methods and justify their choice.
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Affiliation(s)
- Nicole Mealing
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia.
| | - Andrew Hayen
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia.
| | - Anthony T Newall
- School of Public Health and Community Medicine, UNSW Australia, Sydney, NSW, Australia.
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Hagedorn PA, Shah SS, Kirkendall ES. Following the (Clinical Decision) Rules: Opportunities for Improving Safety and Resource Utilization With the Bacterial Meningitis Score. Hosp Pediatr 2016; 6:305-9. [PMID: 27056987 DOI: 10.1542/hpeds.2015-0176] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Bacterial Meningitis Score accurately classifies children with cerebrospinal fluid (CSF) pleocytosis at very low risk (VLR) versus not very low risk (non-VLR) for bacterial meningitis. Most children with CSF pleocytosis detected during emergency department evaluation are hospitalized despite the high accuracy of this prediction rule and the decreasing incidence of bacterial meningitis. The lack of widespread use of this rule may contribute to unnecessary risk exposure and costs. METHODS This cross-sectional study included 1049 patients who, between January 2010 and May 2013, had suspicion for meningitis and underwent both a complete blood cell count and CSF studies during their emergency department evaluation. We then examined their hospitalizations to characterize exposure to drugs, radiologic studies, and the costs associated with their care to determine the safety and value repercussions of these VLR admissions. Primary outcomes include duration of antibiotics, exposure to drugs and radiology studies, safety events, and costs incurred during these VLR admissions. RESULTS Twenty patients classified as VLR were admitted to the hospital. On average they received 35 hours of antibiotic therapy. There was 1 adverse drug event and 1 safety event. CONCLUSIONS The VLR patients admitted to the hospital were exposed to risk and costs despite their low risk stratification. Systematic application of the Bacterial Meningitis Score could prevent these exposures and costs.
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Affiliation(s)
- Philip A Hagedorn
- Division of Hospital Medicine, Cincinnati Children's Hospital and Medical Center Cincinnati, Ohio
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital and Medical Center Cincinnati, Ohio
| | - Eric S Kirkendall
- Division of Hospital Medicine, Cincinnati Children's Hospital and Medical Center Cincinnati, Ohio
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State-of-the-Art Microbiologic Testing for Community-Acquired Meningitis and Encephalitis. J Clin Microbiol 2016; 54:1197-202. [PMID: 26888896 DOI: 10.1128/jcm.00289-16] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Meningitis and encephalitis are potentially life-threatening diseases with a wide array of infectious, postinfectious, and noninfectious causes. Diagnostic testing is central to determining the underlying etiology, treatment, and prognosis, but many patients remain undiagnosed due to suboptimal testing and lack of tests for all pathogens. In this article, we summarize the epidemiology, barriers to diagnosis, and current best tests for meningitis and encephalitis in developed countries. We end with a brief discussion of new test methods, such as multiplex panel-based tests and metagenomic sequencing, which are likely to alter diagnostic strategies for these conditions in the near future.
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Biondi EA, McCulloh RJ, Leyenaar JK, Shin C, Van Wie N, Montalbano A, Williams DJ. Validation of Procedural Codes to Identify Infants Evaluated for Serious Bacterial Infection. Hosp Pediatr 2016; 6:103-107. [PMID: 26762289 DOI: 10.1542/hpeds.2015-0125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE To validate a novel coding method using Current Procedural Terminology, Fourth Edition (CPT-4) codes for identifying infants who underwent a full evaluation for serious bacterial infection (SBI). METHODS We performed a multicenter, retrospective examination to determine the accuracy of a combination of CPT-4 codes for blood, cerebrospinal fluid (CSF), and urine cultures to identify previously healthy infants ≤90 days old admitted to a general care floor and fully evaluated for SBI. Full SBI evaluation was defined as blood, CSF, and urine cultures performed during the emergency department encounter or corresponding hospitalization. Cases were defined as infants who had codes for blood, CSF, and urine cultures (87040, 87070, and either 87086 or 87088), and these were compared with all other encounters. We validated these findings by comparing medical record documentation of blood, CSF, and urine cultures to the corresponding CPT-4 codes, with calculation of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS We identified 8548 qualifying encounters, and 347 (4%) had a combination of CPT-4 codes 87040, 87070, and either 87086 or 87088. This combination had a sensitivity of 100% (95% confidence interval, 98.9-100) and specificity of 98.2% (95% confidence interval, 97.3-98.8) for identifying infants who underwent full SBI evaluation for an unknown source. CONCLUSIONS CPT-4 codes provide an accurate means to identify infants who underwent complete SBI evaluation.
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Affiliation(s)
- Eric A Biondi
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York;
| | - Russell J McCulloh
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - JoAnna K Leyenaar
- Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts; and
| | - Carmen Shin
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Nikole Van Wie
- Department of Pediatrics, University of Rochester Medical Center, Rochester, New York
| | - Amanda Montalbano
- Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Derek J Williams
- Department of Pediatrics, Vanderbilt University School of Medicine, and the Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Aronson PL, Williams DJ, Thurm C, Tieder JS, Alpern ER, Nigrovic LE, Schondelmeyer AC, Balamuth F, Myers AL, McCulloh RJ, Alessandrini EA, Shah SS, Browning WL, Hayes KL, Feldman EA, Neuman MI. Accuracy of diagnosis codes to identify febrile young infants using administrative data. J Hosp Med 2015; 10:787-93. [PMID: 26248691 PMCID: PMC4715646 DOI: 10.1002/jhm.2441] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 06/11/2015] [Accepted: 07/18/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development. OBJECTIVE Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants. DESIGN Retrospective cross-sectional study. SETTING Eight emergency departments in the Pediatric Health Information System. PATIENTS Infants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection. EXPOSURE The ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record. MEASUREMENTS Algorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values. RESULTS Among 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3). CONCLUSIONS A case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation.
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Affiliation(s)
- Paul L. Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, CT
- Address correspondence to: Paul L. Aronson, MD, Section of Pediatric Emergency Medicine, Yale School of Medicine, 100 York Street, Suite 1F, New Haven, CT, 06511. Phone: 203-737-7443, Fax: 203-737-7447,
| | - Derek J. Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Cary Thurm
- Children’s Hospital Association, Overland Park, KS
| | - Joel S. Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Lise E. Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Amanda C. Schondelmeyer
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Fran Balamuth
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Angela L. Myers
- Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Russell J. McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children’s Mercy Hospital, University of Missouri–Kansas City School of Medicine, Kansas City, MO
| | - Evaline A. Alessandrini
- James M. Anderson Center for Health Systems Excellence and Division of Emergency Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Samir S. Shah
- Division of Hospital Medicine, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Division of Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Whitney L. Browning
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children’s Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, TN
| | - Katie L. Hayes
- The Center for Pediatric Clinical Effectiveness and Division of Emergency Medicine, Department of Pediatrics, The Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | - Elana A. Feldman
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children’s Hospital, University of Washington School of Medicine, Seattle, WA
| | - Mark I. Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children’s Hospital, Harvard Medical School, Boston, MA
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Aronson PL, Thurm C, Alpern ER, Alessandrini EA, Williams DJ, Shah SS, Nigrovic LE, McCulloh RJ, Schondelmeyer A, Tieder JS, Neuman MI. Variation in care of the febrile young infant <90 days in US pediatric emergency departments. Pediatrics 2014; 134:667-77. [PMID: 25266437 DOI: 10.1542/peds.2014-1382] [Citation(s) in RCA: 180] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Variation in patient care or outcomes may indicate an opportunity to improve quality of care. We evaluated the variation in testing, treatment, hospitalization rates, and outcomes of febrile young infants in US pediatric emergency departments (EDs). METHODS Retrospective cohort study of infants <90 days of age with a diagnosis code of fever who were evaluated in 1 of 37 pediatric EDs between July 1, 2011 and June 30, 2013. We assessed patient- and hospital-level variation in testing, treatment, and disposition for patients in 3 distinct age groups: ≤28, 29 to 56, and 57 to 89 days. We also compared interhospital variation for 3-day revisits and revisits resulting in hospitalization. RESULTS We identified 35,070 ED visits that met inclusion criteria. The proportion of patients who underwent comprehensive evaluation, defined as urine, serum, and cerebrospinal fluid testing, decreased with increasing patient age: 72.0% (95% confidence interval [CI], 71.0-73.0) of neonates ≤28 days, 49.0% (95% CI, 48.2-49.8) of infants 29 to 56 days, and 13.1% (95% CI, 12.5-13.6) of infants 57 to 89 days. Significant interhospital variation was demonstrated in testing, treatment, and hospitalization rates overall and across all 3 age groups, with little interhospital variation in outcomes. Hospitalization rate in the overall cohort did not correlate with 3-day revisits (R(2) = 0.10, P = .06) or revisits resulting in hospitalization (R(2) = 0.08, P = .09). CONCLUSIONS Substantial patient- and hospital-level variation was observed in the ED management of the febrile young infant, without concomitant differences in outcomes. Strategies to understand and address the modifiable sources of variation are needed.
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Affiliation(s)
- Paul L Aronson
- Department of Pediatrics, Section of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut;
| | - Cary Thurm
- Children's Hospital Association, Overland Park, Kansas
| | - Elizabeth R Alpern
- Division of Emergency Medicine, Lurie Children's Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Derek J Williams
- Division of Hospital Medicine, Department of Pediatrics, The Monroe Carell Jr Children's Hospital at Vanderbilt, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Samir S Shah
- Hospital Medicine, and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lise E Nigrovic
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Russell J McCulloh
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy Hospitals & Clinics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri; and
| | | | - Joel S Tieder
- Division of Hospital Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington
| | - Mark I Neuman
- Division of Emergency Medicine, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
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Bourgeois FT, Monuteaux MC, Stack AM, Neuman MI. Variation in emergency department admission rates in US children's hospitals. Pediatrics 2014; 134:539-45. [PMID: 25113291 PMCID: PMC4144003 DOI: 10.1542/peds.2014-1278] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To measure the hospital-level variation in admission rates for children receiving treatment of common pediatric illnesses across emergency departments (EDs) in US children's hospitals. METHODS We performed a multi-center cross sectional study of children presenting to the EDs of 35 pediatric tertiary-care hospitals participating in the Pediatric Health Information System (PHIS). Admission rates were calculated for visits occurring between January 1, 2009, and December 31, 2012, associated with 1 of 7 common conditions, and corrected to adjust for hospital-level severity of illness. Conditions were selected systematically based on frequency of visits and admission rates. RESULTS A total of 1288706 ED encounters (13.8% of all encounters) were associated with 1 of the 7 conditions of interest. After adjusting for hospital-level severity, the greatest variation in admission rates was observed for concussion (range 5%-72%), followed by pneumonia (19%-69%), and bronchiolitis (19%-65%). The least variation was found among patients presenting with seizures (7%-37%) and kidney and urinary tract infections (6%-37%). Although variability existed in disease-specific admission rates, certain hospitals had consistently higher, and others consistently lower, admission rates. CONCLUSIONS We observed greater than threefold variation in severity-adjusted admission rates for common pediatric conditions across US children's hospitals. Although local practices and hospital-level factors may partly explain this variation, our findings highlight the need for greater focus on the standardization of decisions regarding admission.
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Affiliation(s)
- Florence T Bourgeois
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; andDepartment of Pediatrics, Harvard Medical School, Boston, Massachusetts
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