This study presents an effective strategy to reduce admission rate for children with SCD presenting with VOC. Shorter time to second opiate dosing was also associated with reduced risk of admission.
BACKGROUND AND OBJECTIVES The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services. METHODS Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse. RESULTS Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15–1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15–1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11–1.29; P < .0001). CONCLUSIONS Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.
BACKGROUND AND OBJECTIVES: To determine the effect of discharge criteria on discharge readiness and length of stay (LOS). Discharge inefficiency is a common barrier to hospital flow, affecting admissions, discharges, cost, patient satisfaction, and quality of care. Our center identified increasing discharge efficiency as a method to improve flow and better meet the needs of our patients. METHODS: A multidisciplinary team was assembled to examine discharge efficiency and flow. Discharge criteria were created for the 3 most common diagnoses on the hospital medicine service then expanded to 10 diagnoses 4 months into the project. Discharge workflow was evaluated through swim lane mapping, and barriers were evaluated through fishbone diagrams and a key driver diagram. Progress was assessed every 2 weeks through statistical process control charts. Additional interventions included provider education, daily review of criteria, and autotext added to daily notes. Our primary aim was to increase the percentage of patients discharged within 3 hours of meeting discharge criteria from 44% to 75% within 12 months of project implementation. RESULTS: Discharge within 3 hours as well as 2 hours of meeting criteria improved significantly, from 44% to 87% and from 33% to 78%, respectively. LOS for the 10 diagnoses decreased from 2.89 to 1.47 days, with greatest gains seen for patients with asthma, pneumonia, and bronchiolitis without a change in the 30-day readmission rate. CONCLUSIONS: Discharge criteria for common diagnoses may be an effective way to decrease variability and improve LOS for hospitalized children.
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The "Things We Do for No Reason TM (TWDFNR)" series reviews practices, which have become common parts of hospital care, may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.
A B S T R A C TOBJECTIVES: Despite 2011 guidelines in which it is suggested that treatment of acute immune thrombocytopenia purpura (aITP) is not needed for patients without significant bleeding, only 14% of children treated for aITP have bleeding symptoms. Our aim was to decrease the percentage of children with first-episode aITP who were unnecessarily treated by 50% within 12 months of guideline implementation.METHODS: An intervention was designed by using the precaution-adoption-process model. A standard-of-practice meeting was organized and focused on clinician readiness for change. After education on current evidence and common cognitive errors, consensus clinical guidelines were created. After implementation, an article in a statewide professional newsletter was published to educate community providers. Unnecessary treatment (UT) was defined as treatment of any patient who only had bruising and/or self-resolving nose bleeds. Statistical process control charts were used to track progress, midline shifts were determined by Nelson's rules, and hospital costs were derived from administrative billing data. RESULTS:One hundred children with aITP were seen from January 2013 to September 2018. UT decreased from 70% to a sustained rate of ,30% (P 5 .008), including a mean of 7% over the past 12 months. The admission rate decreased from 100% to 52% (P 5 .013), and the total percentage of patients treated decreased from 100% to 48% (P 5 .016), with both numbers continuing to decline. No adverse bleeding events occurred. An estimated 12 admissions, 4 readmissions, and 5 adverse events were avoided annually. CONCLUSIONS:We demonstrated successful improvement in UT of aITP through an educational intervention informed by the precaution-adoption-process model change theory.
No abstract
Kayser address the important issue of insurance approval for pediatric cancer therapy. As clinicians, we all feel the strain from arduous insurance approval processes that take time and resources away from patient care.What was most surprising about the paper was the near-universal insurance approval for proton beam therapy (PBT) even though it has not yet been convincingly shown to be superior to intensity-modulated radiotherapy (IMRT). The theoretical benefits of achieving higher conformity and sparing healthy tissue are well established. Ojerholm and Hill-Kayser demonstrate that insurance will cover PBT, but does that mean that we should refer? There is evidence that PBT is superior to IMRT and even cost effective in a limited number of clinical scenarios, although the cost-benefit analysis is based on similarly limited data. 6,7 However, the diagnoses described in the paper are much broader including a variety of solid tumors.Proton beam centers are geographically scattered leaving patients to travel long distances for a technology that costs several times as much as IMRT before the cost the family bears for travel, lodging, and food during treatment. The cost of a PBT center ranges from $25 to $250 million. 8 A new PBT center with $100 million of funded debt has to generate $800,000/month to just pay the principle and interest on the debt, which does not include expensive fixed costs like staffing and utilities. 8 These economic pressures create a strong incentive to push the modality based on theoretical benefits before the outcomes data matures. Despite insurance coverage, families are responsible for an ever increasing portion of their bill. We know that medical debt is a leading contributor toward bankruptcy in the United States, 9 and many families of patients with pediatric cancer will develop food, housing, or energy insecurity because of treatment costs. 10 The willingness of insurance companies to approve PBT based on limited evidence puts the onus on clinicians to make careful referrals and push for RCTs. Ojerholm and Hill-Kayser showed that the patient base exists to design appropriately powered RCTs. Pediatric oncology provides many examples of the power of multicentered RCTs to improve outcomes. The best way to ensure insurance coverage is to definitively show that PBT is worth the cost and benefits patients.
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