Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

Knapp, Jane F.; Simon, Stephen D.; Sharma, Vidya

doi:10.1542/peds.2007-3237

Cited by 75 publications

(80 citation statements)

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“…3 With the use of pediatric specific ED quality measures and National Hospital Ambulatory Medical Care Survey (NHAMCS) data, we have reported on the 2005 US ED performance for the care of children with asthma, bronchiolitis, and croup. 2 In that study we found a high rate of use of radiographs in children who present to EDs with these illnesses.…”

Section: Discussionmentioning

confidence: 73%

“…1 Three of the most common pediatric respiratory illnesses, asthma, bronchiolitis, and croup, account for nearly 1 million ED visits each year. 2 Practice variation in US EDs has been previously reported for bronchiolitis. 3 With the use of pediatric specific ED quality measures and National Hospital Ambulatory Medical Care Survey (NHAMCS) data, we have reported on the 2005 US ED performance for the care of children with asthma, bronchiolitis, and croup.…”

Section: Discussionmentioning

confidence: 91%

“…16 The definition of our variable is consistent with this methodology and consistent with our previous work. 2 The protocol for this study was approved by the Children' s Mercy Hospitals and Clinics Pediatric Institutional Review Board.…”

Section: Data Sourcesmentioning

confidence: 99%

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Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

2013

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WHAT'S KNOWN ON THIS SUBJECT: Variation in the emergency department (ED) use of radiographs for asthma, bronchiolitis, and croup exists. Unnecessary radiographs contribute to higher costs of care, decreased ED efficiency, and increased radiation in children.WHAT THIS STUDY ADDS: Despite no changes in guidelines to support routine use, there is a significant upward trend in the use of radiographs for children with emergency department visits for asthma. Pediatric-focused EDs use significantly fewer radiographs for asthma, bronchiolitis, and croup. abstract OBJECTIVES: The objectives were (1) to determine trends in radiograph use in emergency department (ED) care of children with asthma, bronchiolitis, and croup; and (2) to examine the association of patient and hospital factors with variation in radiograph use.METHODS: A retrospective, cross-sectional study of National Hospital Ambulatory Medical Care Survey data between 1995 and 2009 on radiograph use at ED visits in children aged 2 to 18 years with asthma, aged 3 months to 1 year with bronchiolitis, and aged 3 months to 6 years with croup. Odds ratios (ORs) were calculated and adjusted for all factors studied. RESULTS:The use of radiographs for asthma increased significantly over time (OR: 1.06; 95% confidence interval [CI]: 1.03-1.09; P , .001 for trend) but were unchanged for bronchiolitis and croup. Pediatric-focused EDs had lower use for asthma (OR: 0.44; 95% CI: 0.29-0.68), bronchiolitis (OR: 0.37; 95% CI: 0.23-0.59), and croup (OR: 0.34; 95% CI: 0.17-0.68). Compared with the Northeast region, the Midwest and South had statistically higher use of radiographs for all 3 conditions. The Western region had higher use only for asthma (OR: 1.67; 95% CI: 1.07-2.60), and bronchiolitis (OR: 2.94; 95% CI: 1. 48-5.87). No associations were seen for metropolitan statistical area or hospital ownership status. CONCLUSIONS:The ED use of radiographs for children with asthma increased significantly from 1995 to 2009. Reversing this trend could result in substantial cost savings and reduced radiation. Pediatricfocused EDs used significantly fewer radiographs for asthma, bronchiolitis, and croup. The translation of practices from pediatricfocused EDs to all EDs could improve performance. Pediatrics 2013;132:245-252 AUTHORS:

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Section: Discussionmentioning

confidence: 73%

Section: Discussionmentioning

confidence: 91%

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Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

2013

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“…Recent studies have suggested the importance of measuring efficient use of resources for common pediatric ED conditions. 18,19 Efforts to streamline resource use by standardizing practice through evidence-based guidelines have been ongoing, but significant degrees of variation in practice remain. 4,5,19 Current ED quality measures do not include measures of efficient use of resources or how they correlate with ED outcomes.…”

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confidence: 99%

Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency

et al. 2015

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BACKGROUND AND OBJECTIVES: Variability in practice patterns and resource use in the emergency department (ED) can affect costs without affecting outcomes. ED quality measures have not included resource use in relation to ED outcomes and efficiency. Our objectives were to develop a tool for comprehensive physician feedback on practice patterns relative to peers and to study its impact on resource use, quality, and efficiency. METHODS:We evaluated condition-specific resource use (laboratory tests; imaging; antibiotics, intravenous fluids, and ondansetron; admission) by physicians at 2 tertiary pediatric EDs for 4 common conditions (fever, head injury, respiratory illness, gastroenteritis). Resources used, ED length of stay (efficiency measure), and 72-hour return to ED (return rate [RR]) (balancing measure) were reported on scorecards with boxplots showing physicians their practice relative to peers. Quarterly scorecards were distributed for baseline (preintervention, July 2009-August 2010) and postintervention (September 2010-December 2011). Preintervention, postintervention, and trend analyses were performed. RESULTS:In 51 450 patient visits (24 834 preintervention, 26 616 postintervention) seen by 96 physicians, we observed reduced postintervention use of abdominal and pelvic and head computed tomography scans, chest radiographs, intravenous antibiotics, and ondansetron (P , .01 for all). Hospital admissions decreased from 7.4% to 6.7% (P = .002), length of stay from 112 to 108 minutes (P , .001), and RR from 2.2% to 2.0%. Trends for use of laboratory tests and intravenous antibiotics showed significant reduction (P , .001 and P , .05, respectively); admission trends increased, and trends for use of computed tomography scans and plain abdominal radiographs showed no change.CONCLUSIONS: Physician feedback on practice patterns relative to peers results in reduction in resource use for several common ED conditions without adversely affecting ED efficiency or quality of care.There has been considerable focus on overall resource use and cost of care in our nation's emergency departments (EDs), particularly for nonemergent conditions that often make up a large share of the case mix in the typical ED. Additionally, wide variation in practice and resource use that cannot be explained by patient-related factors has been demonstrated in both adults and children, including emergency medicine patients. [1][2][3][4][5][6][7][8][9][10][11][12] Excessive use of resources in health care has not been found to improve quality or outcomes, but it does affect cost. 11,[13][14][15][16] The recent Choosing Wisely initiative encourages every specialty to consider reducing use of tests and procedures that are often unnecessary and sometimes can be harmful. 17 Traditional ED quality measures have included measures of timeliness such

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“…Consequently, interventions that are not efficacious and potentially harmful may be prescribed, whereas interventions that truly are efficacious may be withheld. [1][2][3][4][5] Positive trends in pediatric research have been observed since the first trial was published in 1948. Specifically, there has been a substantial increase in the number of trials published over time, the proportion of randomized to nonrandomized controlled trials, and the proportion of child to adult trials.…”

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confidence: 99%

Standard 2: Containing Risk of Bias

et al. 2012

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DILEMMAThere is a crisis of credibility facing the child health research community because of the paucity of reliable estimates of the effects of interventions in children. Associations between risk of bias assessments and treatment effect estimates have important implications, for the clinician, and the families face important challenges as decisionmakers stemming from results that exaggerate treatment effectiveness or safety. Consequently, interventions that are not efficacious and potentially harmful may be prescribed, whereas interventions that truly are efficacious may be withheld. [1][2][3][4][5] Positive trends in pediatric research have been observed since the first trial was published in 1948. Specifically, there has been a substantial increase in the number of trials published over time, the proportion of randomized to nonrandomized controlled trials, and the proportion of child to adult trials. 6 Reporting of methods has also improved; however, methodological quality remains modest. 6 Three studies have specifically examined risk of bias in pediatric trials by using the Cochrane Risk of Bias tool. [7][8][9] The results are summarized in Table 1 by risk of bias domain. In 2 reviews, the overall risk of bias was unclear or high for the vast majority of trials. 7,8 Both of these articles also revealed that trials at high or unclear risk of bias had exaggerated treatment effects compared with those at low risk of bias. Sequence generation and allocation concealment appear to be the domains that are consistently problematic. Importantly, several variables have been found to be associated with risk of bias including source of funding (industry-sponsored research revealing higher risk of bias), nature of the interventions (behavioral/educational interventions having higher risk of bias), and number of authors (higher risk of bias with fewer authors). 9 These analyses demonstrate that there is substantial room for improvement in the methodological and reporting quality of pediatric trials. The association between risk of bias assessments and treatment effect estimates has important implications for decision-making both in terms of false-positive and false-negative results. In practice, this may result in unrealistic expectations of treatment benefit and safety. Inadequate reporting can also have an impact on systematic reviews, which are being used increasingly as a basis for informed decisionmaking. Although systematic reviews aim to be comprehensive and include all relevant studies, the number of studies contributing to various analyses, be they qualitative or quantitative, is often considerably smaller due to inadequate reporting.Ensuring methodological rigor and complete reporting is essential for informed clinical decision-making. It is critical that issues of bias are recognized and addressed by every person who conducts trials, reviews trials, funds trials, or uses trials to guide practice. This standards article was motivated by 2 key factors: (1) emerging evidence demonstrating methodological flaws a...

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Quality of Care for Common Pediatric Respiratory Illnesses in United States Emergency Departments: Analysis of 2005 National Hospital Ambulatory Medical Care Survey Data

Abstract: Physicians treating children with asthma, bronchiolitis, and croup in US emergency departments are underusing known effective treatments and overusing ineffective or unproven therapies and diagnostic tests.

Cited by 75 publications

References 35 publications

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

Variation and Trends in ED Use of Radiographs for Asthma, Bronchiolitis, and Croup in Children

Impact of Physician Scorecards on Emergency Department Resource Use, Quality, and Efficiency

Standard 2: Containing Risk of Bias

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