Hospital-Based Pediatric Quality Improvement Interventions and Health Disparities: A Scoping Review of the Literature

BACKGROUND AND OBJECTIVES

Quality improvement (QI) has the potential to reduce health disparities through multiple mechanisms, including by standardizing care and addressing social barriers to health. National organizations require that hospital systems integrate equity into quality efforts, but effective approaches remain unclear. We aimed to examine the association of hospital-based pediatric QI interventions and racial and ethnic, language, and socioeconomic disparities in health outcomes.

METHODS

Quantitative studies from January 1, 2000 to December 11, 2023 reporting the effects of pediatric hospital-based QI were selected from PubMed and Embase. Studies were excluded if outcomes were not stratified by race and ethnicity, language, or socioeconomic status. Studies were reviewed in duplicate for inclusion and by 1 author for data extraction.

RESULTS

A total of 22 studies were included. Most studies (n = 19, 86%) revealed preexisting disparities, and 68% of those (n = 13) found disparities reductions post-intervention. Studies with disparity-focused objectives or interventions more commonly found reduced disparities than studies of general QI (85% vs 33%). Hospital-based process standardization was associated with reduced disparities in provider practices. Most interventions associated with reduced disparities in patient-facing outcomes involved community/ambulatory partnership. Limitations included potential exclusion of relevant studies, topic heterogenity, and risk of bias.

CONCLUSIONS

Although the authors of few published hospital-based QI initiatives assessed their equity effect, intentionally designed QI studies were associated with reduced disparities. Interventions focused on care standardization may reduce disparities in care quality, although multilevel interventions are likely needed to affect the health care structures that influence more significant patient outcomes.

Disparities in Racial, Ethnic, and Payer Groups for Pediatric Safety Events in US Hospitals

BACKGROUND AND OBJECTIVES

Health care disparities are pervasive, but little is known about disparities in pediatric safety. We analyzed a national sample of hospitalizations to identify disparities in safety events.

METHODS

In this population-based, retrospective cohort study of the 2019 Kids' Inpatient Database, independent variables were race, ethnicity, and payer. Outcomes were Agency for Healthcare Research and Quality pediatric safety indicators (PDIs). Risk-adjusted odds ratios were calculated using white and private payer reference groups. Differences by payer were evaluated by stratifying race and ethnicity.

RESULTS

Race and ethnicity of the 5 243 750 discharged patients were white, 46%; Hispanic, 19%; Black, 15%; missing, 8%; other race/multiracial, 7%, Asian American/Pacific Islander, 5%; and Native American, 1%. PDI rates (per 10 000 discharges) were 331.4 for neonatal blood stream infection, 267.5 for postoperative respiratory failure, 114.9 for postoperative sepsis, 29.5 for postoperative hemorrhage/hematoma, 5.6 for central-line blood stream infection, 3.5 for accidental puncture/laceration, and 0.7 for iatrogenic pneumothorax. Compared with white patients, Black and Hispanic patients had significantly greater odds in 5 of 7 PDIs; the largest disparities occurred in postoperative sepsis (adjusted odds ratio, 1.55 [1.38-1.73]) for Black patients and postoperative respiratory failure (adjusted odds ratio, 1.34 [1.21-1.49]) for Hispanic patients. Compared with privately insured patients, Medicaid-covered patients had significantly greater odds in 4 of 7 PDIs; the largest disparity occurred in postoperative sepsis (adjusted odds ratios, 1.45 [1.33-1.59]). Stratified analyses demonstrated persistent disparities by race and ethnicity, even among privately insured children.

CONCLUSIONS

Disparities in safety events were identified for Black and Hispanic children, indicating a need for targeted interventions to improve patient safety in the hospital.

Child Opportunity Index and Rehospitalization for Ambulatory Care Sensitive Conditions at US Children's Hospitals

OBJECTIVE

Child Opportunity Index (COI) measures neighborhood contextual factors (education, health and environment, social and economic) that may influence child health. Such factors have been associated with hospitalizations for ambulatory care sensitive conditions (ACSC). Lower COI has been associated with higher health care utilization, yet association with rehospitalization(s) for ACSC remains unknown. Our objective is to determine the association between COI and ACSC rehospitalizations.

METHODS

Multicenter retrospective cohort study of children ages 0 to 17 years with a hospital admission for ambulatory care sensitive conditions in 2017 or 2018. Exposure was COI. Outcome was rehospitalization within 1 year of index admission (analyzed as any or ≥2 rehospitalization) for ACSC. Logistic regression models adjusted for age, sex, severity, and complex and mental health conditions.

RESULTS

The study included 184 478 children. Of hospitalizations, 28.3% were by children from very low COI and 16.5% were by children from very high COI neighborhoods. In risk-adjusted models, ACSC rehospitalization was higher for children from very low COI than very high COI neighborhoods; any rehospitalization occurred for 18.7% from very low COI and 13.5% from very high COI neighborhoods (adjusted odds ratio 1.14 [1.05-1.23]), whereas ≥2 rehospitalization occurred for 4.8% from very low COI and 3.2% from very high COI neighborhoods (odds ratio 1.51 [1.29-1.75]).

CONCLUSIONS

Children from neighborhoods with low COI had higher rehospitalizations for ACSCs. Further research is needed to understand how hospital systems can address social determinants of health in the communities they serve to prevent rehospitalizations.

Barriers and Facilitators of High-Efficiency Clinical Pathway Implementation in Community Hospitals

BACKGROUND

An intervention that involved simultaneously implementing clinical pathways for multiple conditions was tested at a tertiary children's hospital and it improved care quality. We are conducting a randomized trial to evaluate this multicondition pathway intervention in community hospitals. Our objectives in this qualitative study were to prospectively (1) identify implementation barriers and (2) map barriers to facilitators using an established implementation science framework.

METHODS

We recruited participants via site leaders from hospitals enrolled in the trial. We designed an interview guide using the Consolidated Framework for Implementation Research and conducted individual interviews. Analysis was done using constant comparative methods. Anticipated barriers were mapped to facilitators using the Capability, Opportunity, Motivation, Behavior Framework.

RESULTS

Participants from 12 hospitals across the United States were interviewed (n = 21). Major themes regarding the multicondition pathway intervention included clinician perceptions, potential benefits, anticipated barriers/challenges, potential facilitators, and necessary resources. We mapped barriers to additional facilitators using the Capability, Opportunity, Motivation, Behavior framework. To address limited time/bandwidth of clinicians, we will provide Maintenance of Certification credits. To address new staff and trainee turnover, we will provide easily accessible educational videos/resources. To address difficulties in changing practice across other hospital units, we will encourage emergency department engagement. To address parental concerns with deimplementation, we will provide guidance on parent counseling.

CONCLUSIONS

We identified several potential barriers and facilitators for implementation of a multicondition clinical pathway intervention in community hospitals. We also illustrate a prospective process for identifying implementation facilitators.

Pediatric Respiratory Illnesses: An Update on Achievable Benchmarks of Care

BACKGROUND AND OBJECTIVES

Pediatric respiratory illnesses (PRI): asthma, bronchiolitis, pneumonia, croup, and influenza are leading causes of pediatric hospitalizations, and emergency department (ED) visits in the United States. There is a lack of standardized measures to assess the quality of hospital care delivered for these conditions. We aimed to develop a measure set for automated data extraction from administrative data sets and evaluate its performance including updated achievable benchmarks of care (ABC).

METHODS

A multidisciplinary subject-matter experts team selected quality measures from multiple sources. The measure set was applied to the Public Health Information System database (Children's Hospital Association, Lenexa, KS) to cohorts of ED visits and hospitalizations from 2017 to 2019. ABC for pertinent measures and performance gaps of mean values from the ABC were estimated. ABC were compared with previous reports.

RESULTS

The measure set: PRI report includes a total of 94 quality measures. The study cohort included 984 337 episodes of care, and 82.3% were discharged from the ED. Measures with low performance included bronchodilators (19.7%) and chest x-rays (14.4%) for bronchiolitis in the ED. These indicators were (34.6%) and (29.5%) in the hospitalized cohort. In pneumonia, there was a 57.3% use of narrow spectrum antibiotics. In general, compared with previous reports, there was improvement toward optimal performance for the ABCs.

CONCLUSIONS

The PRI report provides performance data including ABC and identifies performance gaps in the quality of care for common respiratory illnesses. Future directions include examining health inequities, and understanding and addressing the effects of the coronavirus disease 2019 pandemic on care quality.

Characterization of Birth Hospitalizations in the United States

OBJECTIVES

A broad understanding of the scope of birth hospitalizations in the United States is lacking. We aimed to describe the demographics and location of birth hospitalizations in the United States and rank the most common and costly conditions documented during birth hospitalizations.

METHODS

We conducted a cross-sectional analysis of the 2019 Kids' Inpatient Database, a nationally-representative administrative database of pediatric discharges. All hospitalizations with the indicator "in-hospital birth" and any categorized by the Pediatric Clinical Classification System as "liveborn" were included. Discharge-level survey weights were used to generate nationally-representative estimates. Primary and secondary conditions coded during birth hospitalizations were categorized using the Pediatric Clinical Classification System, rank-ordered by total prevalence and total marginal costs (calculated using design-adjusted lognormal regression).

RESULTS

In 2019, there were an estimated 5 299 557 pediatric hospitalizations in the US and 67% (n = 3 551 253) were for births, totaling $18.1 billion in cost. Most occurred in private, nonprofit hospitals (n = 2 646 685; 74.5%). Prevalent conditions associated with birth admissions included specified conditions originating in the perinatal period (eg, pregnancy complications, complex births) (n = 1 021 099; 28.8%), neonatal hyperbilirubinemia (n = 540 112; 15.2%), screening or risk for infectious disease (n = 417 421; 11.8%), and preterm newborn (n = 314 288; 8.9%). Conditions with the highest total marginal costs included specified conditions originating in perinatal period ($168.7 million) and neonatal jaundice with preterm delivery ($136.1 million).

CONCLUSIONS

Our study details common and costly areas of focus for future quality improvement and research efforts to improve care during term and preterm infant birth hospitalizations. These include hyperbilirubinemia, infectious disease screening, and perinatal complications.

Neighborhood Child Opportunity and Emergency Department Utilization

The Child Opportunity Index measures the structural neighborhood context that may influence a child's healthy development. We examined relationships between the Child Opportunity Index and emergency department utilization.

BACKGROUND AND OBJECTIVES

The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample.

METHODS

This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission.

RESULTS

We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]).

CONCLUSIONS

Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.

HEROIC Trials to Answer Pragmatic Questions for Hospitalized Children

Although the number of randomized controlled trials (RCTs) published each year involving adult populations is steadily rising, the annual number of RCTs published involving pediatric populations has not changed since 2005. Barriers to the broader utilization of RCTs in pediatrics include a lower prevalence of disease, less available funding, and more complicated regulatory requirements. Although child health researchers have been successful in overcoming these barriers for isolated diseases such as pediatric cancer, common pediatric diseases are underrepresented in RCTs relative to their burden. This article proposes a strategy called High-Efficiency RandOmIzed Controlled (HEROIC) trials to increase RCTs focused on common diseases among hospitalized children. HEROIC trials are multicenter RCTs that pursue the rapid, low-cost accumulation of study participants with minimal burden for individual sites. Five key strategies distinguish HEROIC trials: (1) dispersed low-volume recruitment, in which a large number of sites (50-150 hospitals) enroll a small number of participants per site (2-10 participants per site), (2) incentivizing site leads with authorship, training, education credits, and modest financial support, (3) a focus on pragmatic questions that examine simple, widely used interventions, (4) the use of a single institutional review board, integrated consent, and other efficient solutions to regulatory requirements, and (5) scaling the HEROIC trial strategy to accomplish multiple trials simultaneously. HEROIC trials can boost RCT feasibility and volume to answer fundamental clinical questions and improve care for hospitalized children.

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions

BACKGROUND

Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions.

OBJECTIVE

Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes.

DESIGNS

We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database.

SETTINGS AND PARTICIPANTS

We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis.

INTERVENTION

We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital.

MAIN OUTCOME AND MEASURES

The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions.

RESULTS

Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions.

CONCLUSION

We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.

Child Opportunity Index and Changes in Pediatric Acute Care Utilization in the COVID-19 Pandemic

BACKGROUND

Pediatric acute care utilization decreased dramatically during the coronavirus disease 2019 (COVID-19) pandemic. This study examined the association between the Child Opportunity Index (COI), a multidimensional neighborhood measure of childhood opportunity, and changes in acute care utilization at US pediatric hospitals during the COVID-19 pandemic compared with the previous 3 years.

METHODS

This observational study used administrative data across 41 US-based pediatric hospitals. Children aged 0 to 17 years with emergency department (ED) encounters during the study period were included. The COVID-19 pandemic time period (March 15, 2020-March 14, 2021) was the primary exposure. The primary outcome was the relative volume drop in ED encounters and observation/inpatient admissions through the ED by COI quintile.

RESULTS

Of 12 138 750 encounters, 3 705 320 (30.5%) were among the very low COI quintile. Overall, there was a 46.8% relative volume reduction in the pandemic period compared with the prepandmic period. This drop in volume occurred disproportionately among the very low COI quintile (51.1%) compared with the very high COI quintile (42.8%). The majority of clinical diagnosis groups demonstrated larger relative volume drops among the very low COI quintile.

CONCLUSIONS

Acute care utilization decreased the most among children from very low COI neighborhoods, narrowing previously described acute care utilization disparities. Additional study of patient perspectives on health care needs and access during this period is required to understand these changes.

Common Diagnoses and Costs in Pediatric Hospitalization in the US

This cross-sectional study ranks the prevalent diagnoses among hospitalized children and related costs by hospital type.

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.

Does being a coach benefit clinician-educators? A mixed methods study of faculty self-efficacy, job satisfaction and burnout

INTRODUCTION

Coaching is a growing clinician-educator role. Self-efficacy is a powerful faculty motivator that is associated positively with job satisfaction and negatively with burnout. This study examines self-efficacy, job satisfaction, and burnout in coaches and other clinician-educators.

METHODS

We conducted a mixed methods study using a quantitative survey followed by qualitative interviews of faculty at the University of California, San Francisco. Coaches (funded 20% full-time equivalents), faculty with other funded education positions ("funded"), and faculty without funded education positions ("unfunded") completed a 48-item survey addressing self-efficacy (teaching, professional development, and scholarship), job satisfaction, and burnout. Data were analyzed using analysis of variance followed by post-hoc tests and chi-square tests. To elaborate quantitative results, we conducted qualitative interviews of 15 faculty and analyzed data using framework analysis.

RESULTS

202 of 384 faculty (52.6%) responded to the survey; 187 complete surveys were analyzed. Teaching self-efficacy was similar across groups. Coaches and funded educators had significantly higher professional development self-efficacy and job satisfaction than unfunded educators. Burnout was more prevalent in coaches and unfunded educators. Qualitative analysis yielded three themes: sources of reward, academic identity, and strategies to mitigate burnout. Educator roles provide reward that enhances self-efficacy and job satisfaction but also generate competing demands. Coaches cited challenges in forming professional identities and working with struggling learners.

DISCUSSION

The coaching role provides faculty with benefits similar to other funded educator roles, but the particular demands of the coach role may contribute to burnout.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial

IMPORTANCE

Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients.

OBJECTIVE

To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained.

DESIGN, SETTING, AND PARTICIPANTS

This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020.

INTERVENTIONS

Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards.

MAIN OUTCOMES AND MEASURES

Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models.

RESULTS

A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF.

CONCLUSIONS AND RELEVANCE

In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03924674.

Quality and Safety in Hospital Pediatrics During COVID-19: A National Qualitative Study

OBJECTIVE

To describe challenges in inpatient pediatric quality and safety during the coronavirus disease 2019 (COVID-19) pandemic.

METHODS

In a previous qualitative study, our team sought to broadly describe changes in pediatric inpatient care during the pandemic. For both that study and this ancillary analysis, we purposefully sampled participants from community and children's hospitals in the 6 US states with the highest COVID-19 hospitalization rates from March to May 2020. We recruited 2 to 3 participants from each hospital (administrators, front-line physicians, nurses, caregivers) for semistructured interviews. We used constant comparative methods to identify themes regarding quality and safety challenges during the pandemic.

RESULTS

We interviewed 30 participants from 12 hospitals. Participants described several impacts to clinical workflows, including decreased direct clinician-patient interactions and challenges to communication, partly addressed through innovative use of telehealth technology. Participants reported changes in the discharge and transfer process (eg, discharges, difficulties accessing specialized facilities). Participants also described impacts to hospital operations, including changes in quality monitoring and operations (eg, decreased staff, data collection), increased health risks for clinicians and staff (eg, COVID-19 exposure, testing delays), and staff and supply shortages. Participants voiced concerns that negative quality and safety impacts could include increased risk of preventable safety events and hospital readmissions, and decreased patient engagement, education, and satisfaction.

CONCLUSIONS

We identified several impacts to clinical workflows and hospital operations during the pandemic that may have affected inpatient pediatric care quality and safety. Our findings highlight potentially important areas of focus for planning pandemic recovery, preparing for future pandemics, and conducting future research on inpatient pediatric quality and safety.

Development of a Health Disparities Index: Proof of Concept with Chest Radiography in Asthma

OBJECTIVES

To develop a tool for quantifying health disparity (Health Disparity Index[HDI]) and explore hospital variation measured by this index using chest radiography (CXR) in asthma as the proof of concept.

STUDY DESIGN

This was a retrospective cohort study using the Pediatric Health Information System database including children with asthma between 5 and 18 years old. Inpatient and emergency department (ED) encounters from January 1, 2017, to December 31, 2018, with low or moderate severity were included. Exclusions included hospitals with <10 cases in any racial/ethnic group. The HDI measured variation in CXR use among children with asthma based on race/ethnicity. The HDI was calculated as the absolute difference between maximum and minimum percentages of CXR use (range = 0-100) when there was statistical evidence that the percentages were different.

RESULTS

Data from 36 hospitals included 16 744 inpatient and 75 805 ED encounters. Overall, 19.7% of encounters had a CXR (34.3% for inpatient; 16.5% for ED). In inpatient encounters, 47.2% (17/36) of hospitals had a significant difference in imaging across racial/ethnic groups. Of these, the median hospital-level HDI was 19.4% (IQR 13.5-20.1). In ED encounters, 78.8% (28/36) of hospitals had a statistically significant difference in imaging across racial/ethnic groups, with a median hospital-level HDI of 10.2% (IQR 8.3-14.1). There was no significant association between the inpatient HDI and ED HDI (P = .46).

CONCLUSIONS

The HDI provides a practical measure of disparity. To improve equity in healthcare, metrics are needed that are intuitive, accurate, usable, and actionable. Next steps include application of this index to other conditions.

Changes in pediatric hospital care during the COVID-19 pandemic: a national qualitative study

Background

The COVID-19 pandemic has necessitated rapid changes in healthcare delivery in the United States, including changes in the care of hospitalized children. The objectives of this study were to identify major changes in healthcare delivery for hospitalized children during the COVID-19 pandemic, identify lessons learned from these changes, and compare and contrast the experiences of children’s and community hospitals.

Methods

We purposefully sampled participants from both community and children’s hospitals serving pediatric patients in the six U.S. states with the highest COVID-19 hospitalization rates at the onset of the pandemic. We recruited 2–3 participants from each hospital (mix of administrators, front-line physicians, nurses, and parents/caregivers) for semi-structured interviews. We analyzed interview data using constant comparative methods to identify major themes.

Results

We interviewed 30 participants from 12 hospitals. Participants described how leaders rapidly developed new hospital policies (e.g., directing use of personal protective equipment) and how this was facilitated by reviewing internal and external data frequently and engaging all relevant stakeholders. Hospital leaders optimized communication through regular, transparent, multi-modal, and bi-directional communication. Clinicians increased use of videoconference and telehealth to facilitate physical distancing, but these technologies may have disadvantaged non-English speakers. Due to declining volumes of hospitalized children and surges of adult patients, clinicians newly provided care for hospitalized adults. This was facilitated by developing care teams supported by adult hospitalists, multidisciplinary support via videoconference, and educational resources. Participants described how the pandemic negatively impacted clinicians’ mental health, and they stressed the importance of mental health resources and wellness activities/spaces.

Conclusions

We identified several major changes in inpatient pediatric care delivery during the COVID-19 pandemic, including the adoption of new hospital policies, video communication, staffing models, education strategies, and staff mental health supports. We outline important lessons learned, including strategies for successfully developing new policies, effectively communicating with staff, and supporting clinicians’ expanding scope of practice. Potentially important focus areas in pandemic recovery include assessing and supporting clinicians’ mental health and well-being, re-evaluating trainees’ skills/competencies, and adapting educational strategies as needed. These findings can help guide hospital leaders in supporting pandemic recovery and addressing future crises.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06947-7.

Preventing COVID-19 Transmission in Education Settings

OBJECTIVES

In fall 2020, community hubs opened in San Francisco, California, to support vulnerable groups of students in remote learning. Our objectives were to (1) describe adherence to coronavirus disease 2019 (COVID-19) mitigation policies in these urban, low-income educational settings; (2) assess associations between policy adherence and in-hub COVID-19 transmission; and (3) identify barriers to and facilitators of adherence.

METHODS

We conducted a mixed-methods study from November 2020 to February 2021. We obtained COVID-19 case data from the San Francisco Department of Public Health, conducted field observations to observe adherence to COVID-19 mitigation policies, and surveyed hub leaders about barriers to and facilitators of adherence. We summarized quantitative data using descriptive statistics and qualitative data using thematic content analysis.

RESULTS

A total of 1738 children were enrolled in 85 hubs (39% Hispanic, 29% Black). We observed 54 hubs (n = 1175 observations of children and 295 observations of adults). There was high community-based COVID-19 incidence (2.9-41.2 cases per 100 000 residents per day), with 36 cases in hubs and only 1 case of hub-based transmission (adult to adult). Sixty-seven percent of children and 99% of adults were masked. Fifty-five percent of children and 48% of adults were distanced ≥6 ft. Facilitators of mitigation policies included the following: for masking, reminders, adequate supplies, and "unmasking zones"; for distancing, reminders and distanced seating.

CONCLUSIONS

We directly observed COVID-19 mitigation in educational settings, and we found variable adherence. However, with promotion of multiple policies, there was minimal COVID-19 transmission (despite high community incidence). We detail potential strategies for increasing adherence to COVID-19 mitigation.

Impact of a National Quality Collaborative on Pediatric Asthma Care Quality by Insurance Status

OBJECTIVE

To assess whether disparities in asthma care and outcomes based on insurance type existed before a national quality improvement (QI) collaborative, and to determine the effects of the collaborative on these disparities.

METHODS

Secondary analysis of data from Pathways for Improving Pediatric Asthma Care (PIPA), a national collaborative to standardize emergency department (ED) and inpatient asthma management. PIPA included children aged 2 to 17 with a diagnosis of asthma. Disparities were examined based on insurance status (public vs private). Outcomes included guideline adherence and health care utilization measures, assessed for 12 months before and 15 months after the start of PIPA.

RESULTS

We analyzed 19,204 ED visits and 11,119 hospitalizations from 89 sites. At baseline, children with public insurance were more likely than those with private insurance to receive early administration of corticosteroids (52.3% vs 48.9%, P= .01). However, they were more likely to be admitted (20.0% vs 19.4%, P = .01), have longer inpatient length of stay (31 vs 29 hours, P = .01), and have a readmission/ED revisit within 30 days (7.4% vs 5.6%, P = .02). We assessed the effects of PIPA on these disparities by insurance status and found no significant changes across 6 guideline adherence and 4 health care utilization measures.

CONCLUSION

At baseline, children with public insurance had higher asthma health care utilization than those with private insurance, despite receiving more evidence-based care. The PIPA collaborative did not affect pre-existing disparities in asthma outcomes. Future research should identify effective strategies for leveraging QI to better address disparities.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals

IMPORTANCE

Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes.

OBJECTIVES

To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021.

MAIN OUTCOMES AND MEASURES

The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient.

RESULTS

There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18).

CONCLUSIONS AND RELEVANCE

This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Improving Isotonic Maintenance Intravenous Fluid Use at a Tertiary Children's Hospital

OBJECTIVES

Maintenance intravenous fluids (IVFs) are routinely used in the care of hospitalized children. The American Academy of Pediatrics (AAP) published clinical practice guidelines in November 2018 that recommended the use of isotonic maintenance IVF. Our primary aim was to increase the proportion of hospital days pediatric inpatients were exclusively administered isotonic maintenance IVF to ≥80% by May 2020 at our institution.

METHODS

We conducted a single-center quality improvement (QI) study as part of an AAP collaborative. An interdisciplinary team led QI interventions including providing targeted education to clinicians, integrating guideline recommendations into the electronic medical record, engaging hospital leaders, and providing performance data to clinicians. Our study population included children ages 28 days to 18 years admitted to inpatient wards. Our primary outcome was the proportion of hospital days with exclusive isotonic maintenance IVF use. Balancing measures included transfers to the ICU, ordering of serum sodium laboratory tests, and adverse events. Data were analyzed by using statistical process control.

RESULTS

We analyzed 500 hospital admissions and found a significant increase in exclusive isotonic IVF use (63% to 95%) within 9 months of starting our QI intervention. We found no significant changes in balancing measures (serum sodium laboratory tests [24% to 25%], ICU transfer [0.3% to 1%], adverse events [0.3% to 1%]).

CONCLUSIONS

Our interdisciplinary QI team led interventions that were associated with significant improvements in isotonic IVF use, in accordance with AAP clinical practice guidelines. With our study, we provide detailed guidance on successful interventions for implementing this evidence-based guideline.

High-risk Behavior Screening and Interventions in Hospitalized Adolescents

BACKGROUND AND OBJECTIVES

Risky behaviors are the main threats to adolescents' health. Consequently, guidelines recommend adolescents be screened annually for high-risk behaviors. Our objectives were to (1) determine rates of physician-documented risk behavior screening of hospitalized adolescents, (2) determine rates of positive screening results, and (3) evaluate associations between risk behavior screening and provision of risk behavior-related health care interventions.

METHODS

We conducted a cross-sectional study of patients aged 12 to 24 years admitted to the pediatric hospital medicine service at an urban tertiary children's hospital from January to December 2018. Exclusion criteria were transfer to a different service, nonverbal status, or altered mental status. We reviewed 20 charts per month. Outcomes included (1) documentation of risk behavior screening (mood, sexual activity, substance use, abuse and/or violence, and suicidal ideation), and (2) risk behavior-related health care interventions (eg, testing for sexually transmitted infections). We determined associations between screening and risk behavior-related interventions using χ² tests.

RESULTS

We found that 38% (90 of 240) of adolescents had any documented risk behavior screening, 15% (37 of 240) had screening in 4 of 5 risk behavior domains, and 2% (5 of 240) had screening in all 5 domains. The majority of screened adolescents had a positive screening result (66%), and most with positive results received a risk behavior-related health care intervention (64%-100% across domains). Adolescents with documented screening were significantly more likely to receive a risk behavior-related health care intervention.

CONCLUSIONS

We found low rates of risk behavior screening documentation among hospitalized adolescents. There was a high rate of positive screen results, and those who were documented as screened were more likely to receive risk behavior-related interventions.

Pathways to Improve Pediatric Asthma Care: A Multisite, National Study of Emergency Department Asthma Pathway Implementation

OBJECTIVE

To determine the effects of pediatric asthma pathway implementation in a diverse, national sample of emergency departments (EDs).

STUDY DESIGN

In this quality improvement study, a national sample of EDs were provided pathways to tailor to local needs. Implementation strategies included local champions, external facilitators/mentors, educational seminars, and audit and feedback. Outcomes included systemic corticosteroid administration within 60 minutes (primary), assessment of severity at ED triage, chest radiograph use, hospital admission or transfer for higher level of care, and ED length of stay (balancing). Each month, EDs reviewed all charts (to a maximum of 20) of children ages 2-17 years with a primary diagnosis of asthma. Analyses were done using multilevel regression models with an interrupted time-series approach, adjusting for patient characteristics.

RESULTS

We enrolled 83 EDs (37 in children's hospitals, 46 in community hospitals) and 61 (73%) completed the study (n = 22 963 visits). Pathway implementation was associated with significantly increased odds of systemic corticosteroid administration within 60 minutes of arrival (aOR, 1.26; 95% CI, 1.02-1.55), increased odds of severity assessment at triage (aOR, 1.88; 95% CI, 1.22-2.90), and decreased rate of change in odds of hospital admission/transfer (aOR, 0.97; 95% CI, 0.95-0.99). Pathway implementation was not associated with chest radiograph use or ED length of stay.

CONCLUSIONS

Pathway implementation was associated with improved quality of care for children with asthma in a diverse, national group of EDs.

Pathways for Improving Inpatient Pediatric Asthma Care (PIPA): A Multicenter, National Study

BACKGROUND AND OBJECTIVES

Pathways guide clinicians through evidence-based care of specific conditions. Pathways have been demonstrated to improve inpatient asthma care but mainly in studies at large, tertiary children's hospitals. It remains unclear if these effects are generalizable across diverse hospital settings. Our objective was to improve inpatient asthma care by implementing pathways in a diverse, national sample of hospitals.

METHODS

We used a learning collaborative model. Pathway implementation strategies included local champions, external facilitators and/or mentors, educational seminars, quality improvement methods, and audit and feedback. Outcomes included length of stay (LOS) (primary), early administration of metered-dose inhalers, screening for secondhand tobacco exposure and referral to cessation resources, and 7-day hospital readmissions or emergency revisits (balancing). Hospitals reviewed a sample of up to 20 charts per month of children ages 2 to 17 years who were admitted with a primary diagnosis of asthma (12 months before and 15 months after implementation). Analyses were done by using multilevel regression models with an interrupted time series approach, adjusting for patient characteristics.

RESULTS

Eighty-five hospitals enrolled (40 children's and 45 community); 68 (80%) completed the study (n = 12 013 admissions). Pathways were associated with increases in early administration of metered-dose inhalers (odds ratio: 1.18; 95% confidence interval [CI]: 1.14-1.22) and referral to smoking cessation resources (odds ratio: 1.93; 95% CI: 1.27-2.91) but no statistically significant changes in other outcomes, including LOS (rate ratio: 1.00; 95% CI: 0.96-1.06). Most hospitals (65%) improved in at least 1 outcome.

CONCLUSIONS

Pathways did not significantly impact LOS but did improve quality of asthma care for children in a diverse, national group of hospitals.

Implementing pediatric inpatient asthma pathways

OBJECTIVE

Pathways are succinct, operational versions of evidence-based guidelines. Studies have demonstrated pathways improve quality of care for children hospitalized with asthma, but we have limited information on other key factors to guide hospital leaders and clinicians in pathway implementation efforts. Our objective was to evaluate the adoption, implementation, and reach of inpatient pediatric asthma pathways.

METHODS

This was a mixed-methods study of hospitals participating in a national collaborative to implement pathways. Data sources included electronic surveys of implementation leaders and staff, field observations, and chart review of children ages 2-17 years admitted with a primary diagnosis of asthma. Outcomes included adoption by hospitals, pathway implementation factors, and reach of pathways to children hospitalized with asthma. Quantitative data were analyzed using descriptive statistics and multivariable regression. Qualitative data were analyzed using thematic content analysis.

RESULTS

Eighty-five hospitals enrolled; 68 (80%) adopted/completed the collaborative. These 68 hospitals implemented pathways with overall high fidelity, implementing a median of 5 of 5 core pathway components (Interquartile Range [IQR] 4-5) in a median of 5 months (IQR 3-9). Implementation teams reported a median time cost of 78 h (IQR: 40-120) for implementation. Implementation leaders reported the values of pathway implementation included improvements in care, enhanced interdisciplinary collaboration, and access to educational resources. Leaders reported barriers in modifying electronic health records (EHRs), and only 63% of children had electronic pathway orders placed.

CONCLUSIONS

Hospitals implemented pathways with high fidelity. Barriers in modifying EHRs may have limited the reach of pathways to children hospitalized with asthma.

Implementing Pediatric Asthma Pathways in Community Hospitals: A National Qualitative Study

BACKGROUND

Pathways can improve the quality of care and outcomes for children with asthma; however, we know little about how to successfully implement pathways across diverse hospital settings. Prior studies of pathways have focused on determining clinical effectiveness and the majority were conducted in children's hospitals. These approaches have left crucial gaps in our understanding of how to successfully implement pathways in community hospitals, where most of the children with asthma are treated nationally.

OBJECTIVE

The aim of this study was to identify the key determinants of successful pediatric asthma pathway implementation in community hospitals.

METHODS

We conducted a qualitative study of healthcare providers that served as project leaders in a national collaborative to improve pediatric asthma care. Data were collected by recording semi-structured discussions between project leaders and external facilitators (EF) from December 2017 to April 2018. Using inductive thematic analysis, we identified the themes that describe the key determinants of pathway implementation.

RESULTS

Project leaders (n = 32) from 18 hospitals participated in this study. The key determinants of pathway implementation in community hospitals included (1) building an implementation infrastructure (eg, forming a team of local champions, modifying clinical workflows, delivering education/skills training), (2) engaging and motivating providers (eg, obtaining project buy-in, facilitating multidisciplinary collaboration, handling conflict), (3) addressing organizational and resource limitations (eg, support for electronic medical record integration), and (4) devising implementation solutions with EFs (eg, potential workflow modifications).

CONCLUSIONS

Our identification of the key determinants of pathway implementation may help guide pediatric quality improvement efforts in community hospitals. EFs may play an important role in successfully implementing pathways in community settings.

Associations Between Social Factor Documentation and Hospital Length of Stay and Readmission Among Children

BACKGROUND AND OBJECTIVES

Social risk factors are linked to children's health, but little is known about how frequently these factors are documented using the International Classification of Diseases (ICD) or whether documentation is associated with health care use outcomes. Using a large administrative database of pediatric hospitalizations, we examined the prevalence of ICD social risk code documentation and hypothesized that social code documentation would be associated with longer length of stay (LOS) and readmission.

METHODS

We analyzed hospitalizations of children ages ≤18 using the 2012 Nationwide Readmissions Database. The following ICD social codes were used as predictors: family member with alcohol and/or drug problem, history of abuse, parental separation, foster care, educational circumstance, housing instability, other economic strain, and legal circumstance. Outcomes included long LOS (top quintile) and readmission within 30 days after discharge. Covariates included individual, hospital, and season variables.

RESULTS

Of 926 073 index hospitalizations, 7432 (0.8%) had International Classification of Diseases, Ninth Revision, social codes. Social code documentation was significantly associated with long LOS. Adjusting for covariates, family alcohol and/or drug problem (odds ratio [OR] 1.65; 95% confidence interval [CI] 1.16-2.35), foster care (OR 2.37, 95% CI 1.53-3.65), other economic strain (OR 2.12, 95% CI 1.38-3.26), and legal circumstances (OR 1.66; 95% CI 1.02-2.71) remained significant predictors of long LOS. Social code documentation was not associated with readmission after adjusting for covariates.

CONCLUSIONS

Social ICD codes are associated with prolonged LOS and readmission in pediatric hospitalizations, but they are infrequently documented. Future work exploring these associations could help to determine if addressing social risk factors in inpatient settings might improve child health outcomes.

Feasible Strategies for Sustaining Guideline Adherence: Cross-sectional Analysis of a National Collaborative

Health care providers' adherence to guidelines declines over time, and feasible strategies for sustaining adherence have not yet been identified. We assessed the long-term feasibility of various strategies for sustaining guideline adherence and described factors influencing their use. We conducted a cross-sectional survey (N = 104) of physician leaders who participated in a national collaborative to improve care of infants with suspected sepsis. Data were collected on long-term use of strategies to promote guideline adherence (use, perceived effectiveness, and barriers to use). Sixty (58%) participants from diverse hospital settings responded. There were significant declines in use of quality improvement and educational strategies, largely driven by lack of time or staff resources and competing priorities. Electronic strategies (eg, order sets) and hospital policies or guidelines were feasible to continue long-term after the collaborative ended and were perceived as effective. Clinicians and healthcare leaders should consider prioritizing these strategies in their efforts to improve care and outcomes for children in hospital settings.

Best practices in implementing inpatient pediatric asthma pathways: a qualitative study

Objective: Clinical pathways (operational versions of practice guidelines) can improve guideline adherence and quality of care for children hospitalized with asthma. However, there is limited guidance on how to implement pathways successfully. Our objective was to identify potential best practices in pathway implementation.Methods: In a previous observational study, we identified higher and lower performing children's hospitals based on hospital-level changes in asthma patient length of stay after implementation of a pathway. In this qualitative study, we conducted semi-structured interviews with a purposive sample of healthcare providers involved in pathway implementation at these hospitals. We used constant comparative methods to develop a conceptual model of potential best practices in implementation.Results: Healthcare providers (n = 24) from 6 higher performing and 2 lower performing hospitals were interviewed about pathway implementation. We identified several practices that addressed barriers and promoted successful pathway implementation: (1) utilizing quality improvement (QI) methodology and a data-driven approach helped overcome inertia of current practice; (2) getting teams to commit to shared goals around asthma care helped overcome disagreements in the implementation process; (3) integrating pathways into the electronic medical record decreased some burdens of implementation; (4) leveraging multidisciplinary teams by developing protocols for nurses and/or respiratory therapists to titrate medications reduced variability in provider practice; and (5) engaging hospital leaders with pathway implementation teams helped secure crucial resources.Conclusions: We identified several potential best practices to support pathway implementation. Hospitals implementing pathways should consider applying these strategies to better ensure success in improving quality of asthma care for children.

Limitations of Using Pediatric Respiratory Illness Readmissions to Compare Hospital Performance

BACKGROUND

Adult hospital readmission rates can reliably identify meaningful variation in hospital performance; however, pediatric condition-specific readmission rates are limited by low patient volumes.

OBJECTIVE

To determine if a National Quality Forum (NQF)-endorsed measure for pediatric lower respiratory illness (LRI) 30-day readmission rates can meaningfully identify high- and low-performing hospitals.

DESIGN

Observational, retrospective cohort analysis. We applied the pediatric LRI measure and several variations to evaluate their ability to detect performance differences.

SETTING

Administrative claims from all hospital admissions in California (2012-2014).

PATIENTS

Children (age <18 years) with LRI (primary diagnosis: bronchiolitis, influenza, or pneumonia; or LRI as a secondary diagnosis with a primary diagnosis of respiratory failure, sepsis, bacteremia, or asthma).

MEASUREMENTS

Thirty-day hospital readmission rates and costs. Hierarchical regression models adjusted for age, gender, and chronic conditions were used.

RESULTS

Across all California hospitals admitting children (n = 239) using respiratory readmission rates, no outlier hospitals were identified with (1) the NQF-endorsed metric, (2) inclusion of primary asthma or secondary asthma exacerbation diagnoses, or (3) inclusion of 30-day emergency revisits. By including admissions for asthma, adding emergency revisits, and merging 3 years of data, we identified 9 outlier hospitals (2 high-performers, 7 low-performers). There was no association of hospital readmission rates with costs.

CONCLUSIONS

Using a nationally-endorsed quality measure of inpatient pediatric care, we were unable to identify meaningful variation in hospital performance without broadening the metric definition and merging multiple years of data. Utilizers of pediatric-quality measures should consider modifying metrics to better evaluate the quality of pediatric care at low-volume hospitals.

FUNDING

Supported by the Agency for Healthcare Research and Quality (K08 HS24592 to SVK and U18HS25297 to MDC and NSB) and the National Institute of Child Health and Human Development (K23HD065836 to NSB). The funding agency played no role in the study design; the collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the manuscript for publication.

Effectiveness of Pediatric Asthma Pathways for Hospitalized Children: A Multicenter, National Analysis

OBJECTIVE

To determine if clinical pathways affect care and outcomes for children hospitalized with asthma using a multicenter study.

STUDY DESIGN

This was a retrospective, multicenter cohort study using an administrative database, the Pediatric Health Information System. We evaluated the impact of inpatient pediatric asthma pathways on children age 2-17 years admitted for asthma from 2006 to 2015 in 42 children's hospitals. Date of pathway implementation for each hospital was collected via survey. Using generalized estimating equations with an interrupted time series approach (to account for secular trends), we determined the association of pathway implementation with length of stay (LOS), 30-day readmission, chest radiograph utilization, ipratropium administration >24 hours, and administration of bronchodilators, systemic steroids, and antibiotics. All analyses were risk-adjusted for patient and hospital characteristics.

RESULTS

Clinical pathway implementation was associated with an 8.8% decrease in LOS (95% CI 6.7%-10.9%), 3.1% decrease in hospital costs (95% CI 1.9%-4.3%), increased odds of bronchodilator administration (OR 1.53[1.21-1.95]) and decreased odds of antibiotic administration (OR 0.93[0.87-0.99]) (n = 189 331). We found no associations between pathway implementation and systemic steroid administration, ipratropium administration for >24 hours, chest radiograph utilization, or 30-day readmission.

CONCLUSIONS

Clinical pathways can decrease LOS, costs, and unnecessary antibiotic use without increasing rates of readmissions, leading to higher value care.

Rising utilization of inpatient pediatric asthma pathways

INTRODUCTION

Clinical pathways are detailed care plans that operationalize evidence-based guidelines into an accessible format for health providers. Their goal is to link evidence to practice to optimize patient outcomes and delivery efficiency. It is unknown to what extent inpatient pediatric asthma pathways are being utilized nationally.

OBJECTIVES

(1) Describe inpatient pediatric asthma pathway design and implementation across a large hospital network. (2) Compare characteristics of hospitals with and without pathways.

METHODS

We conducted a descriptive, cross-sectional, survey study of hospitals in the Pediatric Research in Inpatient Settings Network (75% children's hospitals, 25% community hospitals). Our survey determined if each hospital used a pathway and pathway characteristics (e.g. pathway elements, implementation methods). Hospitals with and without pathways were compared using Chi-square tests (categorical variables) and Student's t-tests (continuous variables).

RESULTS

Surveys were distributed to 3-5 potential participants from each hospital and 302 (74%) participants responded, representing 86% (106/123) of surveyed hospitals. From 2005-2015, the proportion of hospitals utilizing inpatient asthma pathways increased from 27% to 86%. We found variation in pathway elements, implementation strategies, electronic medical record integration, and compliance monitoring across hospitals. Hospitals with pathways had larger inpatient pediatric programs [mean 12.1 versus 6.1 full-time equivalents, p = 0.04] and were more commonly free-standing children's hospitals (52% versus 23%, p = 0.05).

CONCLUSIONS

From 2005-2015, there was a dramatic rise in implementation of inpatient pediatric asthma pathways. We found variation in many aspects of pathway design and implementation. Future studies should determine optimal implementation strategies to better support hospital-level efforts in improving pediatric asthma care and outcomes.

Health care for children with diabetes mellitus from low-income families in Ontario and California: a population-based cohort study

BACKGROUND

Children with diabetes mellitus in low-income families have poor outcomes, but little is known as to how this relates to healthcare system structure. Our objective was to gain insight into how best to structure health systems to serve these children by describing their health care use in 2 health system models: a Canadian model, with an organized diabetes care network that includes generalists, and an American model, with targeted support services for children from low-income families.

METHODS

We performed a population-based retrospective cohort study involving children aged 1-17 years with type 1 diabetes mellitus. We used administrative data from between 2009 and 2012 from the California Children's Services program and Ontario. We used Ontario Drug Benefit Program enrolment to identify children from low-income families. Proportions of children receiving 2 or more routine diabetes visits per year were compared using χ2 tests, and diabetes-complication hospital admission rates were compared using direct standardization.

RESULTS

More California children from low-income families (n = 4922) received routine care for diabetes from pediatric endocrinologists (63.9% v. 26.9%, p < 0.001) and used insulin pumps (22.8% v. 16.4%, p < 0.001) than Ontario children (n = 2050).California children from low-income families were less likely than Ontario children to receive 2 visits for routine diabetes care per year (64.7% v. 75.7%, p < 0.001), and had slightly higher per-patient year hospital admission rates for diabetes complications (absolute differences 0.02, 95% confidence interval [CI] 0.02-0.02, for boys; 0.03, 95% CI 0.03-0.03, for girls).

INTERPRETATION

Ontario children from low-income families received more routine diabetes care than did California children from low-income families. Both groups of children had clinically comparable rates of hospital admission for diabetes complications. Diabetes care networks that integrate generalists may play a role in improving access and outcomes for the growing population of children with diabetes.

Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis

CONTEXT

Half of children experience wheezing by age 6 years, and optimal strategies for preventing severe exacerbations are not well defined.

OBJECTIVE

Synthesize the evidence of the effects of daily inhaled corticosteroids (ICS), intermittent ICS, and montelukast in preventing severe exacerbations among preschool children with recurrent wheeze.

DATA SOURCES

Medline (1946, 2/25/15), Embase (1947, 2/25/15), CENTRAL.

STUDY SELECTION

Studies were included based on design (randomized controlled trials), population (children ≤6 years with asthma or recurrent wheeze), intervention and comparison (daily ICS vs placebo, intermittent ICS vs placebo, daily ICS vs intermittent ICS, ICS vs montelukast), and outcome (exacerbations necessitating systemic steroids).

DATA EXTRACTION

Completed by 2 independent reviewers.

RESULTS

Twenty-two studies (N = 4550) were included. Fifteen studies (N = 3278) compared daily ICS with placebo and showed reduced exacerbations with daily medium-dose ICS (risk ratio [RR] 0.70; 95% confidence interval [CI], 0.61-0.79; NNT = 9). Subgroup analysis of children with persistent asthma showed reduced exacerbations with daily ICS compared with placebo (8 studies, N = 2505; RR 0.56; 95% CI, 0.46-0.70; NNT = 11) and daily ICS compared with montelukast (1 study, N = 202; RR 0.59; 95% CI, 0.38-0.92). Subgroup analysis of children with intermittent asthma or viral-triggered wheezing showed reduced exacerbations with preemptive high-dose intermittent ICS compared with placebo (5 studies, N = 422; RR 0.65; 95% CI, 0.51-0.81; NNT = 6).

LIMITATIONS

More studies are needed that directly compare these strategies.

CONCLUSIONS

There is strong evidence to support daily ICS for preventing exacerbations in preschool children with recurrent wheeze, specifically in children with persistent asthma. For preschool children with intermittent asthma or viral-triggered wheezing, there is strong evidence to support intermittent ICS for preventing exacerbations.

Profiling Interfacility Transfers for Hospitalized Pediatric Patients

BACKGROUND AND OBJECTIVE

The hospital-to-hospital transfer of pediatric patients is a common practice that is poorly understood. To better understand this practice, we examined a national database to profile pediatric interfacility transfers.

METHODS

We used the 2012 Kids' Inpatient Database to examine characteristics of hospitalized pediatric patients (<21 years; excluding pregnancy diagnoses) with a transfer admission source. We performed descriptive statistics to compare patient characteristics, utilization, and hospital characteristics between those admitted by transfer versus routine admission. We constructed a multivariable logistic regression model to identify patient characteristics associated with being admitted by transfer versus routine admission.

RESULTS

Of the 5.95 million nonpregnancy hospitalizations in the United States in 2012, 4.4% were admitted by transfer from another hospital. Excluding neonatal hospitalizations, this rate increased to 9.4% of the 2.10 million nonneonatal, nonpregnancy hospitalizations. Eighty-six percent of transfers were to urban teaching hospitals. The most common transfer diagnoses to all hospitals nationally were mood disorder (8.9%), other perinatal conditions (8.7%), prematurity (4.8%), asthma (4.2%), and bronchiolitis (3.8%). In adjusted analysis, factors associated with higher odds of being admitted by transfer included having a neonatal principal diagnosis, male gender, white race, nonprivate insurance, rural residence, higher illness severity, and weekend admission.

CONCLUSIONS

Interfacility transfers are relatively common among hospitalized pediatric patients. Higher odds of admission by transfer are associated not only with higher illness severity but also with principal diagnosis, insurance status, and race. Further studies are needed to identify the etiologies and clinical impacts of identified transfer differences.

Implementation of a neonatal transcutaneous bilirubin screening programme in rural India

BACKGROUND

Universal pre-discharge assessment of risk for neonatal hyperbilirubinaemia is recommended by the American Academy of Pediatrics. A common algorithm is universal transcutaneous bilirubin (TcB) screening, followed by confirmatory total serum bilirubin (TSB) testing for results which cause concern. There is a paucity of data on the feasibility of TcB screening in low-income settings.

OBJECTIVES

To evaluate the acceptability and feasibility of implementing universal TcB screening at a resource-limited hospital in rural India, and to determine if it was associated with increased recognition of high-risk hyperbilirubinaemia.

METHODS

In December 2012 at Vivekananda Memorial Hospital, Karnataka, India, universal TcB screening at 24-48 hours of life was implemented, with TSB estimated if TcB was >75th percentile for age. The proportion of families that provided consent and the proportion of infants who underwent TcB and TSB testing were calculated. The rates of phototherapy pre- and post-implementation and the rate of high-risk hyperbilirubinaemia (TSB >95th percentile for age) post-implementation among infants ≥ 35 weeks gestation were determined.

RESULTS

Parents of 568 of 660 (86%) eligible infants consented to participation. All of these infants were screened with TcB. The proportion who had TSB testing was similar in the pre- (6%) and post-implementation (7%) periods. The rate of phototherapy was not significantly different after implementation (2% vs 3%). Five cases of high-risk hyperbilirubinaemia were identified post-implementation.

CONCLUSIONS

The study demonstrates the acceptability and feasibility of universal TcB screening at a resource-limited hospital in rural India. In settings in which early post-discharge follow-up cannot be assured, TcB can play a valuable role in identifying infants who need evaluation.

Risk Factors for Prolonged Length of Stay or Complications During Pediatric Respiratory Hospitalizations

BACKGROUND AND OBJECTIVES

Respiratory illnesses are the leading cause of pediatric hospitalizations in the United States, and a major focus of efforts to improve quality of care. Understanding factors associated with poor outcomes will allow better targeting of interventions for improving care. The objective of this study was to identify patient and hospital factors associated with prolonged length of stay (LOS) or complications during pediatric hospitalizations for asthma or lower respiratory infection (LRI).

METHODS

Cross-sectional study of hospitalizations of patients <18 years with asthma or LRI (bronchiolitis, influenza, or pneumonia) by using the nationally representative 2012 Kids Inpatient Database. We used multivariable logistic regression models to identify factors associated with prolonged LOS (>90th percentile) or complications (noninvasive ventilation, mechanical ventilation, or death).

RESULTS

For asthma hospitalizations(n = 85 320), risks for both prolonged LOS and complications were increased with each year of age (adjusted odds ratio [AOR] 1.06, 95% confidence interval [CI] 1.05-1.07; AOR 1.05, 95% CI 1.03-1.07, respectively for each outcome) and in children with chronic conditions (AOR 4.87, 95% CI 4.15-5.70; AOR 21.20, 95% CI 15.20-29.57, respectively). For LRI hospitalizations (n = 204 950), risks for prolonged LOS and complications were decreased with each year of age (AOR 0.98, 95% CI 0.97-0.98; AOR 0.95, 95% CI 0.94-0.96, respectively) and increased in children with chronic conditions (AOR 9.86, 95% CI 9.03-10.76; AOR 56.22, 95% CI 46.60-67.82, respectively). Risks for prolonged LOS for asthma were increased in large hospitals (AOR 1.67, 95% CI 1.32-2.11) and urban-teaching hospitals (AOR 1.62, 95% CI 1.33-1.97).

CONCLUSIONS

Older children with asthma, younger children with LRI, children with chronic conditions, and those hospitalized in large urban-teaching hospitals are more vulnerable to prolonged LOS and complications. Future research and policy efforts should evaluate and support interventions to improve outcomes for these high-risk groups (eg, hospital-based care coordination for children with chronic conditions).

National patterns of codeine prescriptions for children in the emergency department

BACKGROUND AND OBJECTIVES

National guidelines have recommended against codeine use in children, but little is known about prescribing patterns in the United States. Our objectives were to assess changes over time in pediatric codeine prescription rates in emergency departments nationally and to determine factors associated with codeine prescription.

METHODS

We performed a serial cross-sectional analysis (2001-2010) of emergency department visits for patients ages 3 to 17 years in the nationally representative National Hospital Ambulatory Medical Care Survey. We determined survey-weighted annual rates of codeine prescriptions and tested for linear trends over time. We used multivariate logistic regression to identify characteristics associated with codeine prescription and interrupted time-series analysis to assess changes in prescriptions for upper respiratory infection (URI) or cough associated with two 2006 national guidelines recommending against its use for these indications.

RESULTS

The proportion of visits (N = 189 million) with codeine prescription decreased from 3.7% to 2.9% during the study period (P = .008). Odds of codeine prescription were higher for children ages 8 to 12 years (odds ratio [OR], 1.42; 95% confidence interval [1.21-1.67]) and among providers outside the northeast. Odds were lower for children who were non-Hispanic black (OR, 0.67 [0.56-0.8]) or with Medicaid (OR, 0.84 [0.71-0.98]). The 2006 guidelines were not associated with a decline in codeine prescriptions for cough or URI visits.

CONCLUSIONS

Although there was a small decline in codeine prescription over 10 years, use for cough or URI did not decline after national guidelines recommending against its use. More effective interventions are needed to prevent codeine prescription to children.