The Autonomy Toolbox: A Multicenter Collaborative to Promote Resident Autonomy

OBJECTIVES

Autonomy is necessary for resident professional development and well-being. A recent focus on patient safety has increased supervision and decreased trainee autonomy. Few validated interventions exist to improve resident autonomy. We aimed to use quality improvement methods to increase our autonomy metric, the Resident Autonomy Score (RAS), by 25% within 1 year and sustain for 6 months.

METHODS

We developed a bundled-intervention approach to improve senior resident (SR) perception of autonomy on Pediatric Hospital Medicine (PHM) services at 5 academic children's hospitals. We surveyed SR and PHM faculty perceptions of autonomy and targeted interventions toward areas with the highest discordance. Interventions included SR and faculty development, expectation-setting huddles, and SR independent rounding. We developed a Resident Autonomy Score (RAS) index to track SR perceptions over time.

RESULTS

Forty-six percent of SRs and 59% of PHM faculty completed the needs assessment survey querying how often SRs were afforded opportunities to provide autonomous medical care. Faculty and SR ratings were discordant in these domains: SR input in medical decisions, SR autonomous decision-making in straightforward cases, follow-through on SR plans, faculty feedback, SR as team leader, and level of attending oversight. The RAS increased by 19% (3.67 to 4.36) 1 month after SR and faculty professional development and before expectation-setting and independent rounding. This increase was sustained throughout the 18-month study period.

CONCLUSIONS

SRs and faculty perceive discordant levels of SR autonomy. We created an adaptable autonomy toolbox that led to sustained improvement in perception of SR autonomy.

Strategies for sustaining high-quality pediatric asthma care in community hospitals

OBJECTIVE

To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals.

DATA SOURCES

Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021).

STUDY DESIGN

Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability.

DATA COLLECTION/EXTRACTION METHODS

We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods.

PRINCIPAL FINDINGS

Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices.

CONCLUSIONS

To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals

IMPORTANCE

The scope of low-value care in children's hospitals is poorly understood.

OBJECTIVE

To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort.

EXPOSURES

Eligible condition-specific hospital encounters.

MAIN OUTCOMES AND MEASURES

The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes.

RESULTS

There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866).

CONCLUSIONS AND RELEVANCE

This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Variation in Early Inflammatory Marker Testing for Infection-Related Hospitalizations in Children

BACKGROUND AND OBJECTIVES

Inflammatory marker testing in children has been identified as a potential area of overuse. We sought to describe variation in early inflammatory marker (C-reactive protein and erythrocyte sedimentation rate) testing for infection-related hospitalizations across children's hospitals and to determine its association with length of stay (LOS), 30-day readmission rate, and cost.

METHODS

We conducted a cross-sectional study of children aged 0 to 17 years with infection-related hospitalizations using the Pediatric Health Information System. After adjusting for patient characteristics, we examined rates of inflammatory marker testing (C-reactive protein or erythrocyte sedimentation rate) during the first 2 days of hospitalization. We used k-means clustering to assign each hospital to 1 of 3 groups on the basis of similarities in adjusted diagnostic testing rates across 12 infectious conditions. Multivariable regression was used to examine the association between hospital testing group and outcomes.

RESULTS

We included 55 771 hospitalizations from 48 hospitals. In 7945 (14.3%), there was inflammatory marker testing in the first 2 days of hospitalization. We observed wide variation in inflammatory marker testing rates across hospitals and infections. Group A hospitals tended to perform more tests than group B or C hospitals (37.4% vs 18.0% vs 10.4%; P < .001) and had the longest adjusted LOS (3.2 vs 2.9 vs 2.8 days; P = .01). There was no significant difference in adjusted 30-day readmission rates or costs.

CONCLUSIONS

Inflammatory marker testing varied widely across hospitals. Hospitals with higher inflammatory testing for one infection tend to test more frequently for other infections and have longer LOS, suggesting opportunities for diagnostic stewardship.

Targeted Education Across Clinical Settings Improves Adherence to Evidence-Based Interventions for Bronchiolitis

Bronchiolitis remains a leading cause of hospitalization of infants. Despite evidence-based recommendations, wide variation in practice remains. A pre-post educational intervention was implemented to improve adherence to bronchiolitis guidelines in emergency and inpatient settings. Among children meeting inclusion criteria (136 pre-intervention, 185 post-intervention), emergency department (ED) bronchodilator use decreased by 64% (P < .001). Steroid use decreased by 71% (P = .002). There was no difference in viral testing, antibiotic use, or chest radiograph acquisition. No differences were seen in the inpatient setting. There was no difference in rate of intensive care unit transfer or length of stay. Post-intervention, children were less likely to receive a bronchodilator in the ED (odds ratio [OR] = 0.15, P < .001). Children with a family history of asthma were more likely to receive a bronchodilator in the ED (OR = 4.25, P < .001). Targeted education across settings contributed to reducing bronchodilator use in the ED. Family history appeared to influence medical decision making.

Pediatric Hospitalizations: Are We Missing an Opportunity to Immunize?

OBJECTIVES

Fewer than half of children receive all recommended immunizations on time. Hospitalizations may be opportunities to address delayed immunizations. Our objectives were to assess (1) prevalence of delayed immunizations among hospitalized patients, (2) missed opportunities to administer delayed immunizations, and (3) time to catch up after discharge.

METHODS

We conducted a retrospective cohort study investigating immunization status of patients 0 to 21 years of age admitted to an academic children's center from 2012 to 2013 at the time of admission, at discharge, and 18 months postdischarge. Immunization catch-up at 18 months postdischarge was defined as having received immunizations due on discharge per Centers for Disease Control and Prevention recommendations. χ² and t test analyses compared characteristics among patients caught up and not caught up at 18 months postdischarge. Analysis of variance and logistic regression analyses compared mean number of immunizations needed and odds of immunization catch-up among age groups. Kaplan-Meier and Cox proportional hazards analyses compared catch-up time by age, race, sex, and insurance.

RESULTS

Among 166 hospitalized patients, 80 were not up to date on immunizations at admission, and only 1 received catch-up immunizations before discharge. Ninety-nine percent (79 of 80) were not up to date on discharge per Centers for Disease Control and Prevention recommendations. Thirty percent (24 of 79), mostly adolescents, were not caught up at 18 months postdischarge. Median postdischarge catch-up time was 3.5 months (range: 0.03-18.0 months). Patients 0 to 35 months of age were more likely to catch up compared with those of other ages (hazard ratio = 2.73; P = .001), with no differences seen when comparing race, sex, or insurance.

CONCLUSIONS

Pediatric hospitalizations provide important opportunities to screen and immunize children.

Patterns of Electrolyte Testing at Children's Hospitals for Common Inpatient Diagnoses

BACKGROUND

Overuse of laboratory testing contributes substantially to health care waste, downstream resource use, and patient harm. Understanding patterns of variation in hospital-level testing across common inpatient diagnoses could identify outliers and inform waste-reduction efforts.

METHODS

We conducted a multicenter retrospective cohort study of pediatric inpatients at 41 children's hospitals using administrative data from 2010 to 2016. Initial electrolyte testing was defined as testing occurring within the first 2 days of an encounter, and repeat testing was defined as subsequent testing within an encounter in which initial testing occurred. To examine if testing rates correlated across diagnoses at the hospital level, we compared risk-adjusted rates for gastroenteritis with a weighted average of risk-adjusted rates in other diagnosis cohorts. For each diagnosis, linear regression was performed to compare initial and subsequent testing.

RESULTS

In 497 719 patient encounters, wide variation was observed across hospitals in adjusted, initial, and repeat testing rates. Hospital-specific rates of testing in gastroenteritis were moderately to strongly correlated with the weighted average of testing in other conditions (initial: r = 0.63; repeat r = 0.83). Within diagnoses, higher hospital-level initial testing rates were associated with significantly increased rates of subsequent testing for all diagnoses except gastroenteritis.

CONCLUSIONS

Among children's hospitals, rates of initial and repeat electrolyte testing vary widely across 8 common inpatient diagnoses. For most diagnoses, hospital-level rates of initial testing were associated with rates of subsequent testing. Consistent rates of testing across multiple diagnoses suggest that hospital-level factors, such as institutional culture, may influence decisions for electrolyte testing.

Impact of an Educational Intervention to Improve Physician Adherence to Bronchiolitis Clinical Practice Guidelines: A Pre-Post Intervention Study

Bronchiolitis is the leading cause of infant hospitalizations in the United States. Despite clinical practice guidelines discouraging the utilization of non-evidence-based therapies, there continues to be wide variation in care and resource utilization. A pre-post physician focused educational intervention was conducted with the aims to reduce the use of non-evidence-based medical therapies, including bronchodilators, among patients admitted for bronchiolitis. Among patients meeting inclusion criteria (pre: n = 45; post: n = 47), bronchodilator use decreased by 50% ( P < .001). Antibiotic use increased by 9% ( P < .02), although results remained within published acceptable utilization rates of less than 19%. There were no statistical differences in chest X-ray, respiratory viral panel, and steroid use. There were no differences in number of pediatric intensive care unit transfers, 30-day readmission rates, and mean length of stay. The findings demonstrate that a physician-focused educational intervention highlighting American Academy of Pediatrics clinical practice guidelines resulted in reduced utilization of bronchodilators.

Parent and Clinician Perspectives on Sustained Behavior Change after a Prenatal Obesity Program: A Qualitative Study

BACKGROUND

Infants of obese women are at a high risk for development of obesity. Prenatal interventions targeting gestational weight gain among obese women have not demonstrated consistent benefits for infant growth trajectories.

METHODS

To better understand why such programs may not influence infant growth, qualitative semi-structured interviews were conducted with 19 mothers who participated in a prenatal nutrition intervention for women with BMI 30 kg/m² or greater, and with 19 clinicians (13 pediatric, 6 obstetrical). Interviews were transcribed and coded with themes emerging inductively from the data, using a grounded theory approach.

RESULTS

Mothers were interviewed a mean of 18 months postpartum and reported successful postnatal maintenance of behaviors that were relevant to the family food environment (Theme 1). Ambivalence around the importance of postnatal behavior maintenance (Theme 2) and enhanced postnatal healthcare (Theme 3) emerged as explanations for the failure of prenatal interventions to influence child growth. Mothers acknowledged their importance as role models for their children's behavior, but they often believed that body habitus was beyond their control. Though mothers attributed prenatal behavior change, in part, to additional support during pregnancy, clinicians had hesitations about providing children of obese parents with additional services postnatally. Both mothers and clinicians perceived a lack of interest or concern about infant growth during pediatric visits (Theme 4).

CONCLUSIONS

Prenatal interventions may better influence childhood growth if paired with improved communication regarding long-term modifiable risks for children. The healthcare community should clarify a package of enhanced preventive services for children with increased risk of developing obesity.