Use of CT in children who visit the ED has increased substantially and occurs primarily at non-pediatric-focused facilities. This underscores the need for special attention to this vulnerable population to ensure that imaging is appropriately ordered, performed, and interpreted.
OBJECTIVE: Recent practice guidelines from the American Academy of Pediatrics recommend limiting use of bronchodilators, corticosteroids, antibiotics, and diagnostic testing for patients with bronchiolitis. We sought to determine the association of the evidence-based guidelines with bronchiolitis care in the emergency department (ED).
METHODS:We analyzed data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of ED visits. We compared utilization for patient visits before and after the publication of the guidelines. We used logistic regression to determine the association of the availability of the guidelines with resource utilization.RESULTS: Bronchodilators were used in 53.8% of patient visits with no differences noted after the introduction of the guidelines (53.6% vs 54.2%, P = .91). Systemic steroids were used in 20.4% of patient visits, and antibiotics were given in 33.2% of visits. There were no changes in the frequency of corticosteroid (21.9% vs 17.8%, P = .31) or antibiotic (33.6% vs 29.7%, P = .51) use. There was an associated decrease in use of chest x-rays (65.3% vs 48.6%, P = .005). This association remained significant after adjusting for patient and hospital characteristics with an adjusted odds ratio of 0.41 (95% confidence interval 0.26-0.67).CONCLUSIONS: For patients seen in the ED with bronchiolitis, utilization of diagnostic imaging has decreased with the availability of the American Academy of Pediatrics practice guidelines. However, there has not been an associated decrease in use of nonrecommended therapies. Targeted efforts will likely be required to change practice significantly.
Students perceived that learning during longitudinal ambulatory clerkships had greater impact on skill enhancement than on attainment of knowledge-related objectives. Sources of variation in student opinion, perceptions of learning as a function of career preference, and correlation of students' perceptions of learning to demonstrable changes in their competence require further investigation.
To examine the association between breastfeeding duration and sources of education about breastfeeding and breast pumps. We analyzed data from the Infant Feeding Practices Survey II (n = 2,586), a national longitudinal consumer-based study. We used χ(2) and ANOVA to contrast categorical and continuous variables, respectively, and logistic regression to model the association between breastfeeding duration and sources of education about breastfeeding and breast pump use. In unadjusted results, multiple sources of breastfeeding and breast pump education were significantly associated with breastfeeding duration. However, in multivariable logistic regression models, there was a negative association between longer breastfeeding duration and receiving breast pump education from a physician/physician assistant (OR 0.58, 95% CI 0.36-0.93); and a positive association between longer breastfeeding duration and receiving breastfeeding education from classes/support group (OR: 1.85, 95% CI: 1.24-2.76) and receiving breast pump education from friends/relatives (OR: 1.70, 95% CI: 1.13-2.55). Although healthcare providers such as physicians and nurses have regular contact with women, the only statistically significant association between breastfeeding and breast pump education from healthcare providers and longer breastfeeding duration was a negative one. This likely reflects time and resource limitations of clinical practice, but may also indicate a need for more consistent training for healthcare providers who provide breastfeeding and breast pump education. Social supports, such as education from classes/support groups and friends/relatives demonstrated positive associations with longer breastfeeding duration. This emphasizes the importance of fostering a positive sphere of influence around breastfeeding women. Future work should also investigate alternative levers of action, such as policies affecting insurance coverage of breast pumps.
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