Showing posts with label quality improvement. Show all posts
Showing posts with label quality improvement. Show all posts

Friday, October 9, 2015

Hospital Variation on Care Utilization by Children with Medical Complexity: Does It Happen and What Do We Do about It?


By: Lewis First, MD, MS; Editor-in-Chief      

          Thanks to the information we can get from payer claim databases, we can learn a lot about variations in care delivery regarding different patient populations. One of those populations is the group of children with medical complexity who receive care daily at our children’s hospitals.  So how consistent is the care delivery across hospitals? Ralston et al. (doi: 10.1542/peds.2014-3920), in an article being released this month in our journal, performed a retrospective population-based observational cohort study that examined payer claims of all children from 1 month to 18 years with medical complexity in Maine, New Hampshire and Vermont.  Sadly there is more variation in care across the 6 hospitals studied in these states than one might suspect.  Where are these variations occurring?  Virtually everywhere--inpatient, outpatient, in intensive care units, and in the emergency department.  Even use of ancillary tests like radiology showed substantive variation.
So what does a study like this suggest?  Drs. Thomson and Shah offer a commentary on variability in health care utilization that accompanies this study and suggest how we can learn from the results being shared in this and other care variation studies that our journal and many others seem to publishing on a frequent basis.  We encourage you to read both the study and commentary and gain a better understanding of how this data might identify best practices for these patients that can then be shared and standardized across hospitals and across states. \
 If your state has an all-payer claims database, you might want to explore what that database is saying about your utilization rates and compare them to the data in this study. If the focus of care nowadays is on managing populations with high quality and lower cost, it is studies like this one that can set the stage to make that happen. 

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Wednesday, August 26, 2015

Are We “Choosing Wisely” to Reduce the Frequency of CT Scans in Children? New Study Tells All!

By: Lewis First, MD, MS; Editor-in-Chief 

          Our journal along with many other peer-reviewed pediatric journals have certainly published our share of studies suggesting the potential radiation risks of computed tomography (CT)  scans—especially multiple CT scan exposures in the same child.  This has led to lower dosages of radiation when children need to use this imaging modality as well as a national campaign to “Image Gently” or to avoid overuse of this readily accessible technology unless it’s medically or surgically indicated relative to other radiologic options.  
       So are trends in CT scanning improving?  Parker et al. (doi: 10.1542/peds.2015-0995) opted to assess these trends in a study being released this week in Pediatrics.  The authors performed a cross-sectional study of 33 tertiary care children’s hospitals using data from the Pediatric Health Information System between 2004 and 2012 looking at trends in not just CT but also ultrasound (US) and magnetic resonance imaging (MRI) for ten leading pediatric diagnoses recorded in this extensive dataset.   
      The results show that CT utilization is decreasing for most of the leading diagnoses and US and MRI trends and that alternative radiologic modalities are increasing.  Just what do the trends show more specifically for what disease?  The answers can be found by carefully scanning through the extensive data shared in this interesting study and then reassuring families that just because a CT scanner is available, doesn’t mean that the benefit of using it outweighs some radiation risks when less risky modalities may exist.

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Friday, August 14, 2015

A Study of Rudeness and Its Effect on Medical Team Performance: How Rude Is That?


By: Lewis First, MD, MS; Editor-in-Chief       

COD Newsroom
          Ever wonder if clinical performance in the ability to diagnose or perform a procedure can be hampered when someone on the team or watching your team is rude to you?  Riskin et al. (doi: 10.1542/peds.2015-1385) decided to answer that question using an innovative methodology involving a training simulation in which one group of neonatal intensive care unit (NICU) teams were observed by someone offering rude comments and the other control teams received neutral comments.   
      While it would be rude for me to give away the results, it would not be rude for me to say that rudeness had adverse consequences on NICU team performance in terms of diagnostic and procedural performance. So have you found the rudeness of others affecting your ability to do what you need to do clinically?   
     If so, what have you done to overcome the problem?  Share with us your anti-rudeness strategies via a response to this blog, an e-letter or by posting your thoughts on our Facebook site or Twitter.

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Monday, June 29, 2015

National Guidelines for Pediatric Illness Management: They May Exist But Do We Ever Read Them, Let Alone Use Them?


By: Lewis First, MD, MS; Editor-in-Chief  

COD Newsroom
          In almost every issue of Pediatrics, we seem to be publishing a set of guidelines for diagnosing, treating, or preventing one pediatric illness or another—all of them as evidence-based as possible in the recommendations they make. Yet despite their import, creation or endorsement by a Section or Committee of the American Academy of Pediatrics (AAP), and despite the publicity they may get in AAP’s Pediatric News and often by the mass media itself, awareness of these guidelines remains less than optimal.  This week we share two studies reinforcing the benefits of using the guidelines as well as the variability and increased cost of care when such guidelines are not used.  The first of these studies by Williams et al. (doi: 10.1542/peds.2014-3047) focuses on 2011 national guidelines for narrow-spectrum antibiotic use in children hospitalized with community acquired pneumonia (CAP) at three children’s hospitals.  To no surprise, when a hospital aggressively promoted and targeted the evidence-based guidelines throughout the institution, the use of penicillin/ampicillin increased significantly and the use of a third generation cephalosporin declined.
Similarly a second study by Mahant et al. (doi: 10.1542/peds.2015-0127) looked at the 2011 guidelines for tonsillectomy perioperative care and then using a retrospective cohort of children in a national database, analyzed perioperative care processes and outcomes pre and post-publication of these guidelines (e.g. use of perioperative dexamethasone, non-use of antibiotics).  While the results suggest more dexamethasone use post guidelines and lower antibiotic usage, the changes are only a few percentage points despite their significance and there was no change in overall outcomes and complications except some increased revisits due to pain issues.  Both studies suggest guidelines will work to improve quality and reduce cost but only if you use them.   
Are you using guidelines to share your clinical management?  If so, which ones?  If not, why not?  Are you guidelined out? Does your EHR system trigger a guideline when you enter a diagnostic code to help direct your management?  We are eager to hear how important clinical guidelines are to you so hopefully these two articles and blog will guide you to a response either below this blog, with an e-letter on with a posting on our Facebook or Twitter websites.

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