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Use of Post-Acute Facility Care in Children Hospitalized With Acute Respiratory Illness
Respiratory illness (RI) is one of the most common reasons for pediatric hospitalization.1 Examples of RI include acute illness, such as bronchiolitis, bacterial pneumonia, and asthma, as well as chronic conditions, such as obstructive sleep apnea and chronic respiratory insufficiency. Hospital care for RI includes monitoring and treatment to optimize oxygenation, ventilation, hydration, and other body functions. Most previously healthy children hospitalized with RI stay in the hospital for a limited duration (eg, a few days) because the severity of their illness is short lived and they quickly return to their previous healthy status.2 However, hospital care is increasing for children with fragile and tenuous health due to complex medical conditions.3 RI is a common reason for hospitalization among these children as well and recovery of respiratory health and function can be slow and protracted for some of them.4 Weeks, months, or longer periods of time may be necessary for the children to return to their previous respiratory baseline health and function after hospital discharge; other children may not return to their baseline.5,6
Hospitalized older adults with high-severity RI are routinely streamlined for transfer to post-acute facility care (PAC) shortly (eg, a few days) after acute-care hospitalization. Nearly 70% of elderly Medicare beneficiaries use PAC following a brief length of stay (LOS) in the acute-care hospital.7 It is believed that PAC helps optimize the patients’ health and functional status and relieves the family caregiving burden that would have occurred at home.8-10 PAC use also helps to shorten acute-care hospitalization for RI while avoiding readmission.8-10 In contrast with adult patients, use of PAC for hospitalized children is not routine.11 While PAC use in children is infrequent, RI is one of the most common reasons for acute admission among children who use it.12
For some children with RI, PAC might be positioned to offer a safe, therapeutic, and high-value setting for pulmonary rehabilitation, as well as related medical, nutritional, functional, and family cares.6 PAC, by design, could possibly help some of the children transition back into their homes and communities. As studies continue to emerge that assess the value of PAC in children, it is important to learn more about the use of PAC in children hospitalized with RI. The objectives were to (1) assess which children admitted with RI are the most likely to use PAC services for recovery and (2) estimate how many hospitalized children not using PAC had the same characteristics as those who did.
METHODS
Study Design, Setting, and Population
We conducted a retrospective cohort analysis of 609,800 hospitalizations for RI occurring from January 1, 2010 to December 31, 2015, in 43 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. All hospitals participating in PHIS are members of the Children’s Hospital Association.13 The Boston Children’s Hospital Institutional Review Board approved this study with a waiver for informed consent.
RI was identified using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS).14 Using diagnosis CCS category 8 (“Diseases of the Respiratory System”) and the procedure CCS category 6 (“Operations on the Respiratory System”), we identified all hospitalizations from the participating hospitals with a principal diagnosis or procedure International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for an RI.
Main Outcome Measure
Discharge disposition following the acute-care hospitalization for RI was the main outcome measure. We used PHIS uniform disposition coding to classify the discharge disposition as transfer to PAC (ie, rehabilitation facility, skilled nursing facility, etc.) vs all other dispositions (ie, routine to home, against medical advice, etc.).12 The PAC disposition category was derived from the Centers for Medicare & Medicaid Services Patient Discharge Status Codes and Hospital Transfer Policies as informed by the National Uniform Billing Committee Official UB-04 Data Specifications Manual, 2008. PAC transfer included disposition to external PAC facilities, as well as to internal, embedded PAC units residing in a few of the acute-care children’s hospitals included in the cohort.
Demographic and Clinical Characteristics
We assessed patient demographic and clinical characteristics that might correlate with PAC use following acute-care hospitalization for RI. Demographic characteristics included gender, age at admission in years, payer (public, private, and other), and race/ethnicity (Hispanic, non-Hispanic black, non-Hispanic white, other).
Clinical characteristics included chronic conditions (type and number) and assistance with medical technology. Chronic condition and medical technology characteristics were assessed with ICD-9-CM diagnosis codes. PHIS contain up to 41 ICD-9-CM diagnosis codes per hospital discharge record. To identify the presence and number of chronic conditions, we used the AHRQ Chronic Condition Indicator system, which categorizes over 14,000 ICD-9-CM diagnosis codes into chronic vs non-chronic conditions.14,15 Children hospitalized with a chronic condition were further classified as having a complex chronic condition (CCC) using Feudtner and colleagues’ ICD-9-CM diagnosis classification scheme.16 CCCs represent defined diagnosis groupings expected to last longer than 12 months and involving either a single organ system, severe enough to require specialty pediatric care and hospitalization, or multiple organ systems.17,18 Hospitalized children who were assisted with medical technology were identified with ICD-9-CM codes indicating the use of a medical device to manage and treat a chronic illness (eg, ventricular shunt to treat hydrocephalus) or to maintain basic body functions necessary for sustaining life (eg, a tracheostomy tube for breathing).19,20 We distinguished children undergoing tracheotomy during hospitalization using ICD-9-CM procedure codes 31.1 and 31.2.
Acute-Care Hospitalization Characteristics
We also assessed the relationship between acute-care hospitalization characteristics and use of PAC after discharge, including US census region, LOS, use of intensive care, number of medication classes administered, and use of enhanced respiratory support. Enhanced respiratory support was defined as use of continuous or bilevel positive airway pressure (CPAP or BiPAP) or mechanical ventilation during the acute-care hospitalization for RI. These respiratory supports were identified using billing data in PHIS.
Statistical Analysis
In bivariable analysis, we compared demographic, clinical, and hospitalization characteristics of hospitalized children with vs without discharge to PAC using Rao-Scott chi-square tests and Wilcoxon rank-sum tests as appropriate. In multivariable analysis, we derived a generalized linear mix effects model with fixed effects for demographic, clinical, and hospitalization characteristics that were associated with PAC at P < 0.1 in bivariable analysis (ie, age, gender, race/ethnicity, payer, medical technology, use of intensive care unit [ICU], use of positive pressure or mechanical ventilation, hospital region, LOS, new tracheostomy, existing tracheostomy, other technologies, number of medications, number of chronic conditions [of any complexity], and type of complex chronic conditions). We controlled for clustering of patients within hospitals by including a random intercept for each hospital. We also assessed combinations of patient characteristics on the likelihood of PAC use with classification and regression tree (CART) modeling. Using CART, we determined which characteristic combinations were associated with the highest and lowest use of PAC using binary split and post-pruning, goodness of fit rules.21 All statistical analyses were performed using SAS v.9.4 (SAS Institute, Cary, NC), and R v.3.2 (R Foundation for Statistical Computing, Vienna, Austria) using the “party” package. The threshold for statistical significance was set at P < 0.05.
RESULTS
Of the 609,800 hospitalizations for RI, PAC use after discharge occurred for 2660 (0.4%). RI discharges to PAC accounted for 2.1% (n = 67,405) of hospital days and 2.7% ($280 million) of hospital cost of all RI hospitalizations. For discharges to PAC, the most common RI were pneumonia (29.1% [n = 773]), respiratory failure or insufficiency (unspecified reason; 22.0% [n = 584]), and upper respiratory infection (12.2% [n = 323]).
Demographic Characteristics
Median age at acute-care admission was higher for PAC vs non-PAC discharges (6 years [interquartile range {IQR} 1-15] vs 2 years [0-7], P < 0.001; Table 1). Hispanic patients accounted for a smaller percentage of RI discharges to PAC vs non-PAC (14.1% vs 21.8%, P < 0.001) and a higher percentage to PAC were for patients with public insurance (75.9% vs 62.5, P < 0.001; Table 1).
Clinical Characteristics
A greater percentage of RI hospitalizations discharged to PAC vs not-PAC had ≥1 CCC (94.9% vs 33.5%), including a neuromuscular CCC (57.5% vs 8.9%) or respiratory CCC (62.5% vs 12.0%), P < 0.001 for all (Table 2). A greater percentage discharged to PAC was assisted with medical technology (83.2% vs 15.1%), including respiratory technology (eg, tracheostomy; 53.8% vs 5.4%) and gastrointestinal technology (eg, gastrostomy; 71.9% vs 11.8%), P < 0.001 for all. Of the children with respiratory technology, 14.8% (n = 394) underwent tracheotomy during the acute-care hospitalization. Children discharged to PAC had a higher percentage of multiple chronic conditions. For example, the percentages of children discharged to PAC vs not with ≥7 conditions were 54.5% vs 7.0% (P < 0.001; Table 2). The most common chronic conditions experienced by children discharged to PAC included epilepsy (41.2%), gastroesophageal reflux (36.6%), cerebral palsy (28.2%), and asthma (18.2%).
Hospitalization Characteristics
Acute-care RI hospitalization median LOS was longer for discharges to PAC vs non-PAC (10 days [IQR 4-27] vs 2 days [IQR 1-4], P < 0.001; Table 1). A greater percentage of discharges to PAC were administered medications from multiple classes during the acute-care RI admission (eg, 54.8% vs 13.4% used medications from ≥7 classes, P < 0.001). A greater percentage of discharges to PAC used intensive care services during the acute-care admission (65.6% vs 22.4%, P < 0.001). A greater percentage of discharges to PAC received CPAP (10.6 vs 5.0%), BiPAP (19.8% vs 11.4%), or mechanical ventilation (52.7% vs 9.1%) during the acute-care RI hospitalization (P < 0.001 for all; Table 1).
Multivariable Analysis of the Likelihood of Post-Acute Care Use Following Discharge
In multivariable analysis, the patient characteristics associated with the highest likelihood of discharge to PAC included ≥11 vs no chronic conditions (odds ratio [OR] 11.8 , 95% CI, 8.0-17.2), ≥9 classes vs no classes of medications administered during the acute-care hospitalization (OR 4.8 , 95% CI, 1.8-13.0), and existing tracheostomy (OR 3.0, [95% CI, 2.6-3.5; Figure 2 and eTable). Patient characteristics associated with a more modest likelihood of discharge to PAC included public vs private insurance (OR 1.8, 95% CI, 1.6-2.0), neuromuscular complex chronic condition (OR 1.6, 95% CI, 1.5-1.8), new tracheostomy (OR 1.9, 95% CI, 1.7-2.2), and use of any enhanced respiratory support (ie, CPAP/BiPAP/mechanical ventilation) during the acute-care hospitalization (OR 1.4, 95% CI, 1.3-1.6; Figure 2 and Supplementary Table).
Classification and Regression Tree Analysis
In the CART analysis, the highest percentage (6.3%) of children hospitalized with RI who were discharged to PAC had the following combination of characteristics: ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Median (IQR) length of acute-care LOS for children with these attributes who were transferred to PAC was 19 (IQR 8-56; range 1-1005) days; LOS remained long (median 13 days [IQR 6-41, range 1-1413]) for children with the same attributes not transferred to PAC (n = 9448). Between these children transferred vs not to PAC, 79.3% vs 65.9% received ICU services; 74.4% vs 73.5% received CPAP, BiPAP, or mechanical ventilation; and 31.0% vs 22.7% underwent tracheotomy during the acute-care hospitalization. Of these children who were not transferred to PAC, 18.9% were discharged to home nursing services.
DISCUSSION
The findings from the present study suggest that patients with RI hospitalization in children’s hospitals who use PAC are medically complex, with high rates of multiple chronic conditions—including cerebral palsy, asthma, chronic respiratory insufficiency, dysphagia, epilepsy, and gastroesophageal reflux—and high rates of technology assistance including enterostomy and tracheostomy. The characteristics of patients most likely to use PAC include long LOS, a large number of chronic conditions, many types of medications administered during the acute-care hospitalization, respiratory technology use, and an underlying neuromuscular condition. Specifically, the highest percentage of children hospitalized with RI who were discharged to PAC had ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Our analysis suggests that there may be a large population of children with these same characteristics who experienced a prolonged LOS but were not transferred to PAC.
There are several reasons to explain why children hospitalized with RI who rely on medical technology, such as existing tracheostomy, are more likely to use PAC. Tracheostomy often indicates the presence of life-limiting impairment in oxygenation or ventilation, thereby representing a high degree of medical fragility. Tracheostomy, in some cases, offers enhanced ability to assist with RI treatment, including establishment of airway clearance of secretions (ie, suctioning and chest physiotherapy), administration of antimicrobials (eg, nebulized antibiotics), and optimization of ventilation (eg, non-invasive positive airway pressure). However, not all acute-care inpatient clinicians have experience and clinical proficiencies in the care of children with pediatric tracheostomy.23 As a result, a more cautious approach, with prolonged LOS and gradual arrival to hospital discharge, is often taken in the acute-care hospital setting for children with tracheostomy. Tracheostomy care delivered during recovery from RI by trained and experienced teams of providers in the PAC setting may be best positioned to help optimize respiratory health and ensure proper family education and readiness to continue care at home.6
Further investigation is needed of the long LOS in children not transferred to PAC who had similar characteristics to those who were transferred. In hospitalized adult patients with RI, PAC is routinely introduced early in the admission process, with anticipated transfer within a few days into the hospitalization. In the current study, LOS was nearly 2 weeks or longer in many children not transferred to PAC who had similar characteristics to those who were transferred. Perhaps some of the children not transferred experienced long LOS in the acute-care hospital because of a limited number of pediatric PAC beds in their local area. Some families of these children may have been offered but declined use of PAC. PAC may not have been offered to some because illness acuity was too high or there was lack of PAC awareness as a possible setting for recovery.
There are several limitations to this study. PHIS does not contain non-freestanding children’s hospitals; therefore, the study results may generalize best to children’s hospitals. PHIS does not contain information on the amount (eg, number of days used), cost, or treatments provided in PAC. Therefore, we were unable to determine the true reasons why children used PAC services following RI hospitalization (eg, for respiratory rehabilitation vs other reasons, such as epilepsy or nutrition/hydration management). Moreover, we could not assess which children truly used PAC for short-term recovery vs longer-term care because they were unable to reside at home (eg, they were too medically complex). We were unable to assess PAC availability (eg, number of beds) in the surrounding areas of the acute-care hospitals in the PHIS database. Although we assessed use of medical technology, PHIS does not contain data on functional status or activities of daily living, which correlate with the use of PAC in adults. We could not distinguish whether children receiving BiPAP, CPAP, or mechanical ventilation during hospitalization were using it chronically. Although higher PAC use was associated with public insurance, due to absent information on the children’s home, family, and social environment, we were unable to assess whether PAC use was influenced by limited caregiving support or resources.
Data on the type and number of chronic conditions are limited by the ICD-9-CM codes available to distinguish them. Although several patient demographic and clinical characteristics were significantly associated with the use of PAC, significance may have occurred because of the large sample size and consequent robust statistical power. This is why we elected to highlight and discuss the characteristics with the strongest and most clinically meaningful associations (eg, multiple chronic conditions). There may be additional characteristics, including social, familial, and community resources, that are not available to assess in PHIS that could have affected PAC use.
Despite these limitations, the current study suggests that the characteristics of children hospitalized with RI who use PAC for recovery are evident and that there is a large population of children with these characteristics who experienced a prolonged LOS that did not result in transfer to PAC. These findings could be used in subsequent studies to help create the base of a matched cohort of children with similar clinical, demographic, and hospitalization characteristics who used vs didn’t use PAC. Comparison of the functional status, health trajectory, and family and/or social attributes of these 2 groups of children, as well as their post-discharge outcomes and utilization (eg, length of PAC stay, emergency department revisits, and acute-care hospital readmissions), could occur with chart review, clinician and parent interview, and other methods. This body of work might ultimately lead to an assessment of value in PAC and potentially help us understand the need for PAC capacity in various communities. In the meantime, clinicians may find it useful to consider the results of the current study when contemplating PAC use in their hospitalized children with RI, including exploration of health system opportunities of clinical collaboration between acute-care children’s hospitals and PAC facilities. Ultimately, all of this work will generate meaningful knowledge regarding the most appropriate, safe, and cost-effective settings for hospitalized children with RI to regain their health.
Acknowledgments
Dr. Berry was supported by the Agency for Healthcare Research and Quality (R21 HS023092-01), the Lucile Packard Foundation for Children’s Health, and Franciscan Hospital for Children. The funders were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclosure: The authors have no financial relationships relevant to this article to disclose.
1. Friedman B, Berdahl T, Simpson LA, et al. Annual report on health care for children and youth in the United States: focus on trends in hospital use and quality. Acad Pediatr. 2011;11(4):263-279. PubMed
2. Srivastava R, Homer CJ. Length of stay for common pediatric conditions: teaching versus nonteaching hospitals. Pediatrics. 2003;112(2):278-281. PubMed
3. Berry JG, Hall M, Hall DE, et al. Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167(2):170-177. PubMed
4. Gold JM, Hall M, Shah SS, et al. Long length of hospital stay in children with medical complexity. J Hosp Med. 2016;11(11):750-756. PubMed
5. Faultner J. Integrating medical plans within family life. JAMA Pediatr. 2014;168(10):891-892. PubMed
6. O’Brien JE, Haley SM, Dumas HM, et al. Outcomes of post-acute hospital episodes for young children requiring airway support. Dev Neurorehabil. 2007;10(3):241-247. PubMed
7. Morley M, Bogasky S, Gage B, et al. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1):mmrr.004.01.b02. PubMed
8. Mentro AM, Steward DK. Caring for medically fragile children in the home: an alternative theoretical approach. Res Theory Nurs Pract. 2002;16(3):161-177. PubMed
9. Thyen U, Kuhlthau K, Perrin JM. Employment, child care, and mental health of mothers caring for children assisted by technology. Pediatrics. 1999;103(6 Pt 1):1235-1242. PubMed
10. Thyen U, Terres NM, Yazdgerdi SR, Perrin JM. Impact of long-term care of children assisted by technology on maternal health. J Dev Behav Pediatr. 1998;19(4):273-282. PubMed
11. O’Brien JE, Berry J, Dumas H. Pediatric Post-acute hospital care: striving for identity and value. Hosp Pediatr. 2015;5(10):548-551. PubMed
12. Berry JG, Hall M, Dumas H, et al. Pediatric hospital discharges to home health and postacute facility care: a national study. JAMA Pediatr. 2016;170(4):326-333. PubMed
13. Children’s Hospital Association. Pediatric Health Information System. https://childrenshospitals.org/Programs-and-Services/Data-Analytics-and-Research/Pediatric-Analytic-Solutions/Pediatric-Health-Information-System. Accessed June 12, 2017.
14. Agency for Healthcare Research and Quality. Chronic Condition Indicator. http://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp. Accessed on June 19, 2017.
15. Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of children with multiple chronic conditions to pediatric hospitalizations in the United States: A Retrospective Cohort Analysis [published online ahead of print June 20, 2017]. Hosp Pediatr. 2017 Jun 20. doi: 10.1542/hpeds.2016-0179. PubMed
16. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14:199. PubMed
17. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529-538. PubMed
18. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics. 2000;106(1 Pt 2):205-209. PubMed
19. Palfrey JS, Walker DK, Haynie M, et al. Technology’s children: report of a statewide census of children dependent on medical supports. Pediatrics. 1991;87(5):611-618. PubMed
20. Feudtner C, Villareale NL, Morray B, Sharp V, Hays RM, Neff JM. Technology-dependency among patients discharged from a children’s hospital: a retrospective cohort study. BMC Pediatr. 2005;5(1):8. PubMed
21. Breiman L, Freidman J, Stone CJ, Olshen RA. Classification and Regression Trees. Belmont, CA: Wadsworth International; 1984.
22. Thomson J, Hall M, Ambroggio L, et al. Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment. Pediatrics. 2016;137(2):e20151612. PubMed
23. Berry JG, Goldmann DA, Mandl KD, et al. Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study. BMC Health Serv Res. 2011;11:117. PubMed
Respiratory illness (RI) is one of the most common reasons for pediatric hospitalization.1 Examples of RI include acute illness, such as bronchiolitis, bacterial pneumonia, and asthma, as well as chronic conditions, such as obstructive sleep apnea and chronic respiratory insufficiency. Hospital care for RI includes monitoring and treatment to optimize oxygenation, ventilation, hydration, and other body functions. Most previously healthy children hospitalized with RI stay in the hospital for a limited duration (eg, a few days) because the severity of their illness is short lived and they quickly return to their previous healthy status.2 However, hospital care is increasing for children with fragile and tenuous health due to complex medical conditions.3 RI is a common reason for hospitalization among these children as well and recovery of respiratory health and function can be slow and protracted for some of them.4 Weeks, months, or longer periods of time may be necessary for the children to return to their previous respiratory baseline health and function after hospital discharge; other children may not return to their baseline.5,6
Hospitalized older adults with high-severity RI are routinely streamlined for transfer to post-acute facility care (PAC) shortly (eg, a few days) after acute-care hospitalization. Nearly 70% of elderly Medicare beneficiaries use PAC following a brief length of stay (LOS) in the acute-care hospital.7 It is believed that PAC helps optimize the patients’ health and functional status and relieves the family caregiving burden that would have occurred at home.8-10 PAC use also helps to shorten acute-care hospitalization for RI while avoiding readmission.8-10 In contrast with adult patients, use of PAC for hospitalized children is not routine.11 While PAC use in children is infrequent, RI is one of the most common reasons for acute admission among children who use it.12
For some children with RI, PAC might be positioned to offer a safe, therapeutic, and high-value setting for pulmonary rehabilitation, as well as related medical, nutritional, functional, and family cares.6 PAC, by design, could possibly help some of the children transition back into their homes and communities. As studies continue to emerge that assess the value of PAC in children, it is important to learn more about the use of PAC in children hospitalized with RI. The objectives were to (1) assess which children admitted with RI are the most likely to use PAC services for recovery and (2) estimate how many hospitalized children not using PAC had the same characteristics as those who did.
METHODS
Study Design, Setting, and Population
We conducted a retrospective cohort analysis of 609,800 hospitalizations for RI occurring from January 1, 2010 to December 31, 2015, in 43 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. All hospitals participating in PHIS are members of the Children’s Hospital Association.13 The Boston Children’s Hospital Institutional Review Board approved this study with a waiver for informed consent.
RI was identified using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS).14 Using diagnosis CCS category 8 (“Diseases of the Respiratory System”) and the procedure CCS category 6 (“Operations on the Respiratory System”), we identified all hospitalizations from the participating hospitals with a principal diagnosis or procedure International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for an RI.
Main Outcome Measure
Discharge disposition following the acute-care hospitalization for RI was the main outcome measure. We used PHIS uniform disposition coding to classify the discharge disposition as transfer to PAC (ie, rehabilitation facility, skilled nursing facility, etc.) vs all other dispositions (ie, routine to home, against medical advice, etc.).12 The PAC disposition category was derived from the Centers for Medicare & Medicaid Services Patient Discharge Status Codes and Hospital Transfer Policies as informed by the National Uniform Billing Committee Official UB-04 Data Specifications Manual, 2008. PAC transfer included disposition to external PAC facilities, as well as to internal, embedded PAC units residing in a few of the acute-care children’s hospitals included in the cohort.
Demographic and Clinical Characteristics
We assessed patient demographic and clinical characteristics that might correlate with PAC use following acute-care hospitalization for RI. Demographic characteristics included gender, age at admission in years, payer (public, private, and other), and race/ethnicity (Hispanic, non-Hispanic black, non-Hispanic white, other).
Clinical characteristics included chronic conditions (type and number) and assistance with medical technology. Chronic condition and medical technology characteristics were assessed with ICD-9-CM diagnosis codes. PHIS contain up to 41 ICD-9-CM diagnosis codes per hospital discharge record. To identify the presence and number of chronic conditions, we used the AHRQ Chronic Condition Indicator system, which categorizes over 14,000 ICD-9-CM diagnosis codes into chronic vs non-chronic conditions.14,15 Children hospitalized with a chronic condition were further classified as having a complex chronic condition (CCC) using Feudtner and colleagues’ ICD-9-CM diagnosis classification scheme.16 CCCs represent defined diagnosis groupings expected to last longer than 12 months and involving either a single organ system, severe enough to require specialty pediatric care and hospitalization, or multiple organ systems.17,18 Hospitalized children who were assisted with medical technology were identified with ICD-9-CM codes indicating the use of a medical device to manage and treat a chronic illness (eg, ventricular shunt to treat hydrocephalus) or to maintain basic body functions necessary for sustaining life (eg, a tracheostomy tube for breathing).19,20 We distinguished children undergoing tracheotomy during hospitalization using ICD-9-CM procedure codes 31.1 and 31.2.
Acute-Care Hospitalization Characteristics
We also assessed the relationship between acute-care hospitalization characteristics and use of PAC after discharge, including US census region, LOS, use of intensive care, number of medication classes administered, and use of enhanced respiratory support. Enhanced respiratory support was defined as use of continuous or bilevel positive airway pressure (CPAP or BiPAP) or mechanical ventilation during the acute-care hospitalization for RI. These respiratory supports were identified using billing data in PHIS.
Statistical Analysis
In bivariable analysis, we compared demographic, clinical, and hospitalization characteristics of hospitalized children with vs without discharge to PAC using Rao-Scott chi-square tests and Wilcoxon rank-sum tests as appropriate. In multivariable analysis, we derived a generalized linear mix effects model with fixed effects for demographic, clinical, and hospitalization characteristics that were associated with PAC at P < 0.1 in bivariable analysis (ie, age, gender, race/ethnicity, payer, medical technology, use of intensive care unit [ICU], use of positive pressure or mechanical ventilation, hospital region, LOS, new tracheostomy, existing tracheostomy, other technologies, number of medications, number of chronic conditions [of any complexity], and type of complex chronic conditions). We controlled for clustering of patients within hospitals by including a random intercept for each hospital. We also assessed combinations of patient characteristics on the likelihood of PAC use with classification and regression tree (CART) modeling. Using CART, we determined which characteristic combinations were associated with the highest and lowest use of PAC using binary split and post-pruning, goodness of fit rules.21 All statistical analyses were performed using SAS v.9.4 (SAS Institute, Cary, NC), and R v.3.2 (R Foundation for Statistical Computing, Vienna, Austria) using the “party” package. The threshold for statistical significance was set at P < 0.05.
RESULTS
Of the 609,800 hospitalizations for RI, PAC use after discharge occurred for 2660 (0.4%). RI discharges to PAC accounted for 2.1% (n = 67,405) of hospital days and 2.7% ($280 million) of hospital cost of all RI hospitalizations. For discharges to PAC, the most common RI were pneumonia (29.1% [n = 773]), respiratory failure or insufficiency (unspecified reason; 22.0% [n = 584]), and upper respiratory infection (12.2% [n = 323]).
Demographic Characteristics
Median age at acute-care admission was higher for PAC vs non-PAC discharges (6 years [interquartile range {IQR} 1-15] vs 2 years [0-7], P < 0.001; Table 1). Hispanic patients accounted for a smaller percentage of RI discharges to PAC vs non-PAC (14.1% vs 21.8%, P < 0.001) and a higher percentage to PAC were for patients with public insurance (75.9% vs 62.5, P < 0.001; Table 1).
Clinical Characteristics
A greater percentage of RI hospitalizations discharged to PAC vs not-PAC had ≥1 CCC (94.9% vs 33.5%), including a neuromuscular CCC (57.5% vs 8.9%) or respiratory CCC (62.5% vs 12.0%), P < 0.001 for all (Table 2). A greater percentage discharged to PAC was assisted with medical technology (83.2% vs 15.1%), including respiratory technology (eg, tracheostomy; 53.8% vs 5.4%) and gastrointestinal technology (eg, gastrostomy; 71.9% vs 11.8%), P < 0.001 for all. Of the children with respiratory technology, 14.8% (n = 394) underwent tracheotomy during the acute-care hospitalization. Children discharged to PAC had a higher percentage of multiple chronic conditions. For example, the percentages of children discharged to PAC vs not with ≥7 conditions were 54.5% vs 7.0% (P < 0.001; Table 2). The most common chronic conditions experienced by children discharged to PAC included epilepsy (41.2%), gastroesophageal reflux (36.6%), cerebral palsy (28.2%), and asthma (18.2%).
Hospitalization Characteristics
Acute-care RI hospitalization median LOS was longer for discharges to PAC vs non-PAC (10 days [IQR 4-27] vs 2 days [IQR 1-4], P < 0.001; Table 1). A greater percentage of discharges to PAC were administered medications from multiple classes during the acute-care RI admission (eg, 54.8% vs 13.4% used medications from ≥7 classes, P < 0.001). A greater percentage of discharges to PAC used intensive care services during the acute-care admission (65.6% vs 22.4%, P < 0.001). A greater percentage of discharges to PAC received CPAP (10.6 vs 5.0%), BiPAP (19.8% vs 11.4%), or mechanical ventilation (52.7% vs 9.1%) during the acute-care RI hospitalization (P < 0.001 for all; Table 1).
Multivariable Analysis of the Likelihood of Post-Acute Care Use Following Discharge
In multivariable analysis, the patient characteristics associated with the highest likelihood of discharge to PAC included ≥11 vs no chronic conditions (odds ratio [OR] 11.8 , 95% CI, 8.0-17.2), ≥9 classes vs no classes of medications administered during the acute-care hospitalization (OR 4.8 , 95% CI, 1.8-13.0), and existing tracheostomy (OR 3.0, [95% CI, 2.6-3.5; Figure 2 and eTable). Patient characteristics associated with a more modest likelihood of discharge to PAC included public vs private insurance (OR 1.8, 95% CI, 1.6-2.0), neuromuscular complex chronic condition (OR 1.6, 95% CI, 1.5-1.8), new tracheostomy (OR 1.9, 95% CI, 1.7-2.2), and use of any enhanced respiratory support (ie, CPAP/BiPAP/mechanical ventilation) during the acute-care hospitalization (OR 1.4, 95% CI, 1.3-1.6; Figure 2 and Supplementary Table).
Classification and Regression Tree Analysis
In the CART analysis, the highest percentage (6.3%) of children hospitalized with RI who were discharged to PAC had the following combination of characteristics: ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Median (IQR) length of acute-care LOS for children with these attributes who were transferred to PAC was 19 (IQR 8-56; range 1-1005) days; LOS remained long (median 13 days [IQR 6-41, range 1-1413]) for children with the same attributes not transferred to PAC (n = 9448). Between these children transferred vs not to PAC, 79.3% vs 65.9% received ICU services; 74.4% vs 73.5% received CPAP, BiPAP, or mechanical ventilation; and 31.0% vs 22.7% underwent tracheotomy during the acute-care hospitalization. Of these children who were not transferred to PAC, 18.9% were discharged to home nursing services.
DISCUSSION
The findings from the present study suggest that patients with RI hospitalization in children’s hospitals who use PAC are medically complex, with high rates of multiple chronic conditions—including cerebral palsy, asthma, chronic respiratory insufficiency, dysphagia, epilepsy, and gastroesophageal reflux—and high rates of technology assistance including enterostomy and tracheostomy. The characteristics of patients most likely to use PAC include long LOS, a large number of chronic conditions, many types of medications administered during the acute-care hospitalization, respiratory technology use, and an underlying neuromuscular condition. Specifically, the highest percentage of children hospitalized with RI who were discharged to PAC had ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Our analysis suggests that there may be a large population of children with these same characteristics who experienced a prolonged LOS but were not transferred to PAC.
There are several reasons to explain why children hospitalized with RI who rely on medical technology, such as existing tracheostomy, are more likely to use PAC. Tracheostomy often indicates the presence of life-limiting impairment in oxygenation or ventilation, thereby representing a high degree of medical fragility. Tracheostomy, in some cases, offers enhanced ability to assist with RI treatment, including establishment of airway clearance of secretions (ie, suctioning and chest physiotherapy), administration of antimicrobials (eg, nebulized antibiotics), and optimization of ventilation (eg, non-invasive positive airway pressure). However, not all acute-care inpatient clinicians have experience and clinical proficiencies in the care of children with pediatric tracheostomy.23 As a result, a more cautious approach, with prolonged LOS and gradual arrival to hospital discharge, is often taken in the acute-care hospital setting for children with tracheostomy. Tracheostomy care delivered during recovery from RI by trained and experienced teams of providers in the PAC setting may be best positioned to help optimize respiratory health and ensure proper family education and readiness to continue care at home.6
Further investigation is needed of the long LOS in children not transferred to PAC who had similar characteristics to those who were transferred. In hospitalized adult patients with RI, PAC is routinely introduced early in the admission process, with anticipated transfer within a few days into the hospitalization. In the current study, LOS was nearly 2 weeks or longer in many children not transferred to PAC who had similar characteristics to those who were transferred. Perhaps some of the children not transferred experienced long LOS in the acute-care hospital because of a limited number of pediatric PAC beds in their local area. Some families of these children may have been offered but declined use of PAC. PAC may not have been offered to some because illness acuity was too high or there was lack of PAC awareness as a possible setting for recovery.
There are several limitations to this study. PHIS does not contain non-freestanding children’s hospitals; therefore, the study results may generalize best to children’s hospitals. PHIS does not contain information on the amount (eg, number of days used), cost, or treatments provided in PAC. Therefore, we were unable to determine the true reasons why children used PAC services following RI hospitalization (eg, for respiratory rehabilitation vs other reasons, such as epilepsy or nutrition/hydration management). Moreover, we could not assess which children truly used PAC for short-term recovery vs longer-term care because they were unable to reside at home (eg, they were too medically complex). We were unable to assess PAC availability (eg, number of beds) in the surrounding areas of the acute-care hospitals in the PHIS database. Although we assessed use of medical technology, PHIS does not contain data on functional status or activities of daily living, which correlate with the use of PAC in adults. We could not distinguish whether children receiving BiPAP, CPAP, or mechanical ventilation during hospitalization were using it chronically. Although higher PAC use was associated with public insurance, due to absent information on the children’s home, family, and social environment, we were unable to assess whether PAC use was influenced by limited caregiving support or resources.
Data on the type and number of chronic conditions are limited by the ICD-9-CM codes available to distinguish them. Although several patient demographic and clinical characteristics were significantly associated with the use of PAC, significance may have occurred because of the large sample size and consequent robust statistical power. This is why we elected to highlight and discuss the characteristics with the strongest and most clinically meaningful associations (eg, multiple chronic conditions). There may be additional characteristics, including social, familial, and community resources, that are not available to assess in PHIS that could have affected PAC use.
Despite these limitations, the current study suggests that the characteristics of children hospitalized with RI who use PAC for recovery are evident and that there is a large population of children with these characteristics who experienced a prolonged LOS that did not result in transfer to PAC. These findings could be used in subsequent studies to help create the base of a matched cohort of children with similar clinical, demographic, and hospitalization characteristics who used vs didn’t use PAC. Comparison of the functional status, health trajectory, and family and/or social attributes of these 2 groups of children, as well as their post-discharge outcomes and utilization (eg, length of PAC stay, emergency department revisits, and acute-care hospital readmissions), could occur with chart review, clinician and parent interview, and other methods. This body of work might ultimately lead to an assessment of value in PAC and potentially help us understand the need for PAC capacity in various communities. In the meantime, clinicians may find it useful to consider the results of the current study when contemplating PAC use in their hospitalized children with RI, including exploration of health system opportunities of clinical collaboration between acute-care children’s hospitals and PAC facilities. Ultimately, all of this work will generate meaningful knowledge regarding the most appropriate, safe, and cost-effective settings for hospitalized children with RI to regain their health.
Acknowledgments
Dr. Berry was supported by the Agency for Healthcare Research and Quality (R21 HS023092-01), the Lucile Packard Foundation for Children’s Health, and Franciscan Hospital for Children. The funders were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclosure: The authors have no financial relationships relevant to this article to disclose.
Respiratory illness (RI) is one of the most common reasons for pediatric hospitalization.1 Examples of RI include acute illness, such as bronchiolitis, bacterial pneumonia, and asthma, as well as chronic conditions, such as obstructive sleep apnea and chronic respiratory insufficiency. Hospital care for RI includes monitoring and treatment to optimize oxygenation, ventilation, hydration, and other body functions. Most previously healthy children hospitalized with RI stay in the hospital for a limited duration (eg, a few days) because the severity of their illness is short lived and they quickly return to their previous healthy status.2 However, hospital care is increasing for children with fragile and tenuous health due to complex medical conditions.3 RI is a common reason for hospitalization among these children as well and recovery of respiratory health and function can be slow and protracted for some of them.4 Weeks, months, or longer periods of time may be necessary for the children to return to their previous respiratory baseline health and function after hospital discharge; other children may not return to their baseline.5,6
Hospitalized older adults with high-severity RI are routinely streamlined for transfer to post-acute facility care (PAC) shortly (eg, a few days) after acute-care hospitalization. Nearly 70% of elderly Medicare beneficiaries use PAC following a brief length of stay (LOS) in the acute-care hospital.7 It is believed that PAC helps optimize the patients’ health and functional status and relieves the family caregiving burden that would have occurred at home.8-10 PAC use also helps to shorten acute-care hospitalization for RI while avoiding readmission.8-10 In contrast with adult patients, use of PAC for hospitalized children is not routine.11 While PAC use in children is infrequent, RI is one of the most common reasons for acute admission among children who use it.12
For some children with RI, PAC might be positioned to offer a safe, therapeutic, and high-value setting for pulmonary rehabilitation, as well as related medical, nutritional, functional, and family cares.6 PAC, by design, could possibly help some of the children transition back into their homes and communities. As studies continue to emerge that assess the value of PAC in children, it is important to learn more about the use of PAC in children hospitalized with RI. The objectives were to (1) assess which children admitted with RI are the most likely to use PAC services for recovery and (2) estimate how many hospitalized children not using PAC had the same characteristics as those who did.
METHODS
Study Design, Setting, and Population
We conducted a retrospective cohort analysis of 609,800 hospitalizations for RI occurring from January 1, 2010 to December 31, 2015, in 43 freestanding children’s hospitals in the Pediatric Health Information Systems (PHIS) dataset. All hospitals participating in PHIS are members of the Children’s Hospital Association.13 The Boston Children’s Hospital Institutional Review Board approved this study with a waiver for informed consent.
RI was identified using the Agency for Healthcare Research and Quality (AHRQ) Clinical Classification System (CCS).14 Using diagnosis CCS category 8 (“Diseases of the Respiratory System”) and the procedure CCS category 6 (“Operations on the Respiratory System”), we identified all hospitalizations from the participating hospitals with a principal diagnosis or procedure International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code for an RI.
Main Outcome Measure
Discharge disposition following the acute-care hospitalization for RI was the main outcome measure. We used PHIS uniform disposition coding to classify the discharge disposition as transfer to PAC (ie, rehabilitation facility, skilled nursing facility, etc.) vs all other dispositions (ie, routine to home, against medical advice, etc.).12 The PAC disposition category was derived from the Centers for Medicare & Medicaid Services Patient Discharge Status Codes and Hospital Transfer Policies as informed by the National Uniform Billing Committee Official UB-04 Data Specifications Manual, 2008. PAC transfer included disposition to external PAC facilities, as well as to internal, embedded PAC units residing in a few of the acute-care children’s hospitals included in the cohort.
Demographic and Clinical Characteristics
We assessed patient demographic and clinical characteristics that might correlate with PAC use following acute-care hospitalization for RI. Demographic characteristics included gender, age at admission in years, payer (public, private, and other), and race/ethnicity (Hispanic, non-Hispanic black, non-Hispanic white, other).
Clinical characteristics included chronic conditions (type and number) and assistance with medical technology. Chronic condition and medical technology characteristics were assessed with ICD-9-CM diagnosis codes. PHIS contain up to 41 ICD-9-CM diagnosis codes per hospital discharge record. To identify the presence and number of chronic conditions, we used the AHRQ Chronic Condition Indicator system, which categorizes over 14,000 ICD-9-CM diagnosis codes into chronic vs non-chronic conditions.14,15 Children hospitalized with a chronic condition were further classified as having a complex chronic condition (CCC) using Feudtner and colleagues’ ICD-9-CM diagnosis classification scheme.16 CCCs represent defined diagnosis groupings expected to last longer than 12 months and involving either a single organ system, severe enough to require specialty pediatric care and hospitalization, or multiple organ systems.17,18 Hospitalized children who were assisted with medical technology were identified with ICD-9-CM codes indicating the use of a medical device to manage and treat a chronic illness (eg, ventricular shunt to treat hydrocephalus) or to maintain basic body functions necessary for sustaining life (eg, a tracheostomy tube for breathing).19,20 We distinguished children undergoing tracheotomy during hospitalization using ICD-9-CM procedure codes 31.1 and 31.2.
Acute-Care Hospitalization Characteristics
We also assessed the relationship between acute-care hospitalization characteristics and use of PAC after discharge, including US census region, LOS, use of intensive care, number of medication classes administered, and use of enhanced respiratory support. Enhanced respiratory support was defined as use of continuous or bilevel positive airway pressure (CPAP or BiPAP) or mechanical ventilation during the acute-care hospitalization for RI. These respiratory supports were identified using billing data in PHIS.
Statistical Analysis
In bivariable analysis, we compared demographic, clinical, and hospitalization characteristics of hospitalized children with vs without discharge to PAC using Rao-Scott chi-square tests and Wilcoxon rank-sum tests as appropriate. In multivariable analysis, we derived a generalized linear mix effects model with fixed effects for demographic, clinical, and hospitalization characteristics that were associated with PAC at P < 0.1 in bivariable analysis (ie, age, gender, race/ethnicity, payer, medical technology, use of intensive care unit [ICU], use of positive pressure or mechanical ventilation, hospital region, LOS, new tracheostomy, existing tracheostomy, other technologies, number of medications, number of chronic conditions [of any complexity], and type of complex chronic conditions). We controlled for clustering of patients within hospitals by including a random intercept for each hospital. We also assessed combinations of patient characteristics on the likelihood of PAC use with classification and regression tree (CART) modeling. Using CART, we determined which characteristic combinations were associated with the highest and lowest use of PAC using binary split and post-pruning, goodness of fit rules.21 All statistical analyses were performed using SAS v.9.4 (SAS Institute, Cary, NC), and R v.3.2 (R Foundation for Statistical Computing, Vienna, Austria) using the “party” package. The threshold for statistical significance was set at P < 0.05.
RESULTS
Of the 609,800 hospitalizations for RI, PAC use after discharge occurred for 2660 (0.4%). RI discharges to PAC accounted for 2.1% (n = 67,405) of hospital days and 2.7% ($280 million) of hospital cost of all RI hospitalizations. For discharges to PAC, the most common RI were pneumonia (29.1% [n = 773]), respiratory failure or insufficiency (unspecified reason; 22.0% [n = 584]), and upper respiratory infection (12.2% [n = 323]).
Demographic Characteristics
Median age at acute-care admission was higher for PAC vs non-PAC discharges (6 years [interquartile range {IQR} 1-15] vs 2 years [0-7], P < 0.001; Table 1). Hispanic patients accounted for a smaller percentage of RI discharges to PAC vs non-PAC (14.1% vs 21.8%, P < 0.001) and a higher percentage to PAC were for patients with public insurance (75.9% vs 62.5, P < 0.001; Table 1).
Clinical Characteristics
A greater percentage of RI hospitalizations discharged to PAC vs not-PAC had ≥1 CCC (94.9% vs 33.5%), including a neuromuscular CCC (57.5% vs 8.9%) or respiratory CCC (62.5% vs 12.0%), P < 0.001 for all (Table 2). A greater percentage discharged to PAC was assisted with medical technology (83.2% vs 15.1%), including respiratory technology (eg, tracheostomy; 53.8% vs 5.4%) and gastrointestinal technology (eg, gastrostomy; 71.9% vs 11.8%), P < 0.001 for all. Of the children with respiratory technology, 14.8% (n = 394) underwent tracheotomy during the acute-care hospitalization. Children discharged to PAC had a higher percentage of multiple chronic conditions. For example, the percentages of children discharged to PAC vs not with ≥7 conditions were 54.5% vs 7.0% (P < 0.001; Table 2). The most common chronic conditions experienced by children discharged to PAC included epilepsy (41.2%), gastroesophageal reflux (36.6%), cerebral palsy (28.2%), and asthma (18.2%).
Hospitalization Characteristics
Acute-care RI hospitalization median LOS was longer for discharges to PAC vs non-PAC (10 days [IQR 4-27] vs 2 days [IQR 1-4], P < 0.001; Table 1). A greater percentage of discharges to PAC were administered medications from multiple classes during the acute-care RI admission (eg, 54.8% vs 13.4% used medications from ≥7 classes, P < 0.001). A greater percentage of discharges to PAC used intensive care services during the acute-care admission (65.6% vs 22.4%, P < 0.001). A greater percentage of discharges to PAC received CPAP (10.6 vs 5.0%), BiPAP (19.8% vs 11.4%), or mechanical ventilation (52.7% vs 9.1%) during the acute-care RI hospitalization (P < 0.001 for all; Table 1).
Multivariable Analysis of the Likelihood of Post-Acute Care Use Following Discharge
In multivariable analysis, the patient characteristics associated with the highest likelihood of discharge to PAC included ≥11 vs no chronic conditions (odds ratio [OR] 11.8 , 95% CI, 8.0-17.2), ≥9 classes vs no classes of medications administered during the acute-care hospitalization (OR 4.8 , 95% CI, 1.8-13.0), and existing tracheostomy (OR 3.0, [95% CI, 2.6-3.5; Figure 2 and eTable). Patient characteristics associated with a more modest likelihood of discharge to PAC included public vs private insurance (OR 1.8, 95% CI, 1.6-2.0), neuromuscular complex chronic condition (OR 1.6, 95% CI, 1.5-1.8), new tracheostomy (OR 1.9, 95% CI, 1.7-2.2), and use of any enhanced respiratory support (ie, CPAP/BiPAP/mechanical ventilation) during the acute-care hospitalization (OR 1.4, 95% CI, 1.3-1.6; Figure 2 and Supplementary Table).
Classification and Regression Tree Analysis
In the CART analysis, the highest percentage (6.3%) of children hospitalized with RI who were discharged to PAC had the following combination of characteristics: ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Median (IQR) length of acute-care LOS for children with these attributes who were transferred to PAC was 19 (IQR 8-56; range 1-1005) days; LOS remained long (median 13 days [IQR 6-41, range 1-1413]) for children with the same attributes not transferred to PAC (n = 9448). Between these children transferred vs not to PAC, 79.3% vs 65.9% received ICU services; 74.4% vs 73.5% received CPAP, BiPAP, or mechanical ventilation; and 31.0% vs 22.7% underwent tracheotomy during the acute-care hospitalization. Of these children who were not transferred to PAC, 18.9% were discharged to home nursing services.
DISCUSSION
The findings from the present study suggest that patients with RI hospitalization in children’s hospitals who use PAC are medically complex, with high rates of multiple chronic conditions—including cerebral palsy, asthma, chronic respiratory insufficiency, dysphagia, epilepsy, and gastroesophageal reflux—and high rates of technology assistance including enterostomy and tracheostomy. The characteristics of patients most likely to use PAC include long LOS, a large number of chronic conditions, many types of medications administered during the acute-care hospitalization, respiratory technology use, and an underlying neuromuscular condition. Specifically, the highest percentage of children hospitalized with RI who were discharged to PAC had ≥6 chronic conditions, ≥7 classes of medications administered, and respiratory technology. Our analysis suggests that there may be a large population of children with these same characteristics who experienced a prolonged LOS but were not transferred to PAC.
There are several reasons to explain why children hospitalized with RI who rely on medical technology, such as existing tracheostomy, are more likely to use PAC. Tracheostomy often indicates the presence of life-limiting impairment in oxygenation or ventilation, thereby representing a high degree of medical fragility. Tracheostomy, in some cases, offers enhanced ability to assist with RI treatment, including establishment of airway clearance of secretions (ie, suctioning and chest physiotherapy), administration of antimicrobials (eg, nebulized antibiotics), and optimization of ventilation (eg, non-invasive positive airway pressure). However, not all acute-care inpatient clinicians have experience and clinical proficiencies in the care of children with pediatric tracheostomy.23 As a result, a more cautious approach, with prolonged LOS and gradual arrival to hospital discharge, is often taken in the acute-care hospital setting for children with tracheostomy. Tracheostomy care delivered during recovery from RI by trained and experienced teams of providers in the PAC setting may be best positioned to help optimize respiratory health and ensure proper family education and readiness to continue care at home.6
Further investigation is needed of the long LOS in children not transferred to PAC who had similar characteristics to those who were transferred. In hospitalized adult patients with RI, PAC is routinely introduced early in the admission process, with anticipated transfer within a few days into the hospitalization. In the current study, LOS was nearly 2 weeks or longer in many children not transferred to PAC who had similar characteristics to those who were transferred. Perhaps some of the children not transferred experienced long LOS in the acute-care hospital because of a limited number of pediatric PAC beds in their local area. Some families of these children may have been offered but declined use of PAC. PAC may not have been offered to some because illness acuity was too high or there was lack of PAC awareness as a possible setting for recovery.
There are several limitations to this study. PHIS does not contain non-freestanding children’s hospitals; therefore, the study results may generalize best to children’s hospitals. PHIS does not contain information on the amount (eg, number of days used), cost, or treatments provided in PAC. Therefore, we were unable to determine the true reasons why children used PAC services following RI hospitalization (eg, for respiratory rehabilitation vs other reasons, such as epilepsy or nutrition/hydration management). Moreover, we could not assess which children truly used PAC for short-term recovery vs longer-term care because they were unable to reside at home (eg, they were too medically complex). We were unable to assess PAC availability (eg, number of beds) in the surrounding areas of the acute-care hospitals in the PHIS database. Although we assessed use of medical technology, PHIS does not contain data on functional status or activities of daily living, which correlate with the use of PAC in adults. We could not distinguish whether children receiving BiPAP, CPAP, or mechanical ventilation during hospitalization were using it chronically. Although higher PAC use was associated with public insurance, due to absent information on the children’s home, family, and social environment, we were unable to assess whether PAC use was influenced by limited caregiving support or resources.
Data on the type and number of chronic conditions are limited by the ICD-9-CM codes available to distinguish them. Although several patient demographic and clinical characteristics were significantly associated with the use of PAC, significance may have occurred because of the large sample size and consequent robust statistical power. This is why we elected to highlight and discuss the characteristics with the strongest and most clinically meaningful associations (eg, multiple chronic conditions). There may be additional characteristics, including social, familial, and community resources, that are not available to assess in PHIS that could have affected PAC use.
Despite these limitations, the current study suggests that the characteristics of children hospitalized with RI who use PAC for recovery are evident and that there is a large population of children with these characteristics who experienced a prolonged LOS that did not result in transfer to PAC. These findings could be used in subsequent studies to help create the base of a matched cohort of children with similar clinical, demographic, and hospitalization characteristics who used vs didn’t use PAC. Comparison of the functional status, health trajectory, and family and/or social attributes of these 2 groups of children, as well as their post-discharge outcomes and utilization (eg, length of PAC stay, emergency department revisits, and acute-care hospital readmissions), could occur with chart review, clinician and parent interview, and other methods. This body of work might ultimately lead to an assessment of value in PAC and potentially help us understand the need for PAC capacity in various communities. In the meantime, clinicians may find it useful to consider the results of the current study when contemplating PAC use in their hospitalized children with RI, including exploration of health system opportunities of clinical collaboration between acute-care children’s hospitals and PAC facilities. Ultimately, all of this work will generate meaningful knowledge regarding the most appropriate, safe, and cost-effective settings for hospitalized children with RI to regain their health.
Acknowledgments
Dr. Berry was supported by the Agency for Healthcare Research and Quality (R21 HS023092-01), the Lucile Packard Foundation for Children’s Health, and Franciscan Hospital for Children. The funders were not involved in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclosure: The authors have no financial relationships relevant to this article to disclose.
1. Friedman B, Berdahl T, Simpson LA, et al. Annual report on health care for children and youth in the United States: focus on trends in hospital use and quality. Acad Pediatr. 2011;11(4):263-279. PubMed
2. Srivastava R, Homer CJ. Length of stay for common pediatric conditions: teaching versus nonteaching hospitals. Pediatrics. 2003;112(2):278-281. PubMed
3. Berry JG, Hall M, Hall DE, et al. Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167(2):170-177. PubMed
4. Gold JM, Hall M, Shah SS, et al. Long length of hospital stay in children with medical complexity. J Hosp Med. 2016;11(11):750-756. PubMed
5. Faultner J. Integrating medical plans within family life. JAMA Pediatr. 2014;168(10):891-892. PubMed
6. O’Brien JE, Haley SM, Dumas HM, et al. Outcomes of post-acute hospital episodes for young children requiring airway support. Dev Neurorehabil. 2007;10(3):241-247. PubMed
7. Morley M, Bogasky S, Gage B, et al. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1):mmrr.004.01.b02. PubMed
8. Mentro AM, Steward DK. Caring for medically fragile children in the home: an alternative theoretical approach. Res Theory Nurs Pract. 2002;16(3):161-177. PubMed
9. Thyen U, Kuhlthau K, Perrin JM. Employment, child care, and mental health of mothers caring for children assisted by technology. Pediatrics. 1999;103(6 Pt 1):1235-1242. PubMed
10. Thyen U, Terres NM, Yazdgerdi SR, Perrin JM. Impact of long-term care of children assisted by technology on maternal health. J Dev Behav Pediatr. 1998;19(4):273-282. PubMed
11. O’Brien JE, Berry J, Dumas H. Pediatric Post-acute hospital care: striving for identity and value. Hosp Pediatr. 2015;5(10):548-551. PubMed
12. Berry JG, Hall M, Dumas H, et al. Pediatric hospital discharges to home health and postacute facility care: a national study. JAMA Pediatr. 2016;170(4):326-333. PubMed
13. Children’s Hospital Association. Pediatric Health Information System. https://childrenshospitals.org/Programs-and-Services/Data-Analytics-and-Research/Pediatric-Analytic-Solutions/Pediatric-Health-Information-System. Accessed June 12, 2017.
14. Agency for Healthcare Research and Quality. Chronic Condition Indicator. http://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp. Accessed on June 19, 2017.
15. Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of children with multiple chronic conditions to pediatric hospitalizations in the United States: A Retrospective Cohort Analysis [published online ahead of print June 20, 2017]. Hosp Pediatr. 2017 Jun 20. doi: 10.1542/hpeds.2016-0179. PubMed
16. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14:199. PubMed
17. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529-538. PubMed
18. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics. 2000;106(1 Pt 2):205-209. PubMed
19. Palfrey JS, Walker DK, Haynie M, et al. Technology’s children: report of a statewide census of children dependent on medical supports. Pediatrics. 1991;87(5):611-618. PubMed
20. Feudtner C, Villareale NL, Morray B, Sharp V, Hays RM, Neff JM. Technology-dependency among patients discharged from a children’s hospital: a retrospective cohort study. BMC Pediatr. 2005;5(1):8. PubMed
21. Breiman L, Freidman J, Stone CJ, Olshen RA. Classification and Regression Trees. Belmont, CA: Wadsworth International; 1984.
22. Thomson J, Hall M, Ambroggio L, et al. Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment. Pediatrics. 2016;137(2):e20151612. PubMed
23. Berry JG, Goldmann DA, Mandl KD, et al. Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study. BMC Health Serv Res. 2011;11:117. PubMed
1. Friedman B, Berdahl T, Simpson LA, et al. Annual report on health care for children and youth in the United States: focus on trends in hospital use and quality. Acad Pediatr. 2011;11(4):263-279. PubMed
2. Srivastava R, Homer CJ. Length of stay for common pediatric conditions: teaching versus nonteaching hospitals. Pediatrics. 2003;112(2):278-281. PubMed
3. Berry JG, Hall M, Hall DE, et al. Inpatient growth and resource use in 28 children’s hospitals: a longitudinal, multi-institutional study. JAMA Pediatr. 2013;167(2):170-177. PubMed
4. Gold JM, Hall M, Shah SS, et al. Long length of hospital stay in children with medical complexity. J Hosp Med. 2016;11(11):750-756. PubMed
5. Faultner J. Integrating medical plans within family life. JAMA Pediatr. 2014;168(10):891-892. PubMed
6. O’Brien JE, Haley SM, Dumas HM, et al. Outcomes of post-acute hospital episodes for young children requiring airway support. Dev Neurorehabil. 2007;10(3):241-247. PubMed
7. Morley M, Bogasky S, Gage B, et al. Medicare post-acute care episodes and payment bundling. Medicare Medicaid Res Rev. 2014;4(1):mmrr.004.01.b02. PubMed
8. Mentro AM, Steward DK. Caring for medically fragile children in the home: an alternative theoretical approach. Res Theory Nurs Pract. 2002;16(3):161-177. PubMed
9. Thyen U, Kuhlthau K, Perrin JM. Employment, child care, and mental health of mothers caring for children assisted by technology. Pediatrics. 1999;103(6 Pt 1):1235-1242. PubMed
10. Thyen U, Terres NM, Yazdgerdi SR, Perrin JM. Impact of long-term care of children assisted by technology on maternal health. J Dev Behav Pediatr. 1998;19(4):273-282. PubMed
11. O’Brien JE, Berry J, Dumas H. Pediatric Post-acute hospital care: striving for identity and value. Hosp Pediatr. 2015;5(10):548-551. PubMed
12. Berry JG, Hall M, Dumas H, et al. Pediatric hospital discharges to home health and postacute facility care: a national study. JAMA Pediatr. 2016;170(4):326-333. PubMed
13. Children’s Hospital Association. Pediatric Health Information System. https://childrenshospitals.org/Programs-and-Services/Data-Analytics-and-Research/Pediatric-Analytic-Solutions/Pediatric-Health-Information-System. Accessed June 12, 2017.
14. Agency for Healthcare Research and Quality. Chronic Condition Indicator. http://www.hcup-us.ahrq.gov/toolssoftware/chronic/chronic.jsp. Accessed on June 19, 2017.
15. Berry JG, Ash AS, Cohen E, Hasan F, Feudtner C, Hall M. Contributions of children with multiple chronic conditions to pediatric hospitalizations in the United States: A Retrospective Cohort Analysis [published online ahead of print June 20, 2017]. Hosp Pediatr. 2017 Jun 20. doi: 10.1542/hpeds.2016-0179. PubMed
16. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation. BMC Pediatr. 2014;14:199. PubMed
17. Cohen E, Kuo DZ, Agrawal R, et al. Children with medical complexity: an emerging population for clinical and research initiatives. Pediatrics. 2011;127(3):529-538. PubMed
18. Feudtner C, Christakis DA, Connell FA. Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997. Pediatrics. 2000;106(1 Pt 2):205-209. PubMed
19. Palfrey JS, Walker DK, Haynie M, et al. Technology’s children: report of a statewide census of children dependent on medical supports. Pediatrics. 1991;87(5):611-618. PubMed
20. Feudtner C, Villareale NL, Morray B, Sharp V, Hays RM, Neff JM. Technology-dependency among patients discharged from a children’s hospital: a retrospective cohort study. BMC Pediatr. 2005;5(1):8. PubMed
21. Breiman L, Freidman J, Stone CJ, Olshen RA. Classification and Regression Trees. Belmont, CA: Wadsworth International; 1984.
22. Thomson J, Hall M, Ambroggio L, et al. Aspiration and Non-Aspiration Pneumonia in Hospitalized Children With Neurologic Impairment. Pediatrics. 2016;137(2):e20151612. PubMed
23. Berry JG, Goldmann DA, Mandl KD, et al. Health information management and perceptions of the quality of care for children with tracheotomy: a qualitative study. BMC Health Serv Res. 2011;11:117. PubMed
© 2017 Society of Hospital Medicine
Choosing Wisely in Pediatric Medicine
Overuse in medicine is a significant and under‐recognized problem. Don Berwick estimated that waste accounts for at least 20% of healthcare expenditures in the United States, with overtreatment as one of the largest categories.[1] A commentary by Schroeder et al. challenged pediatricians to incorporate this knowledge into our own patient safety and quality movement.[2] Recently published data suggest that we are far from achieving the patient safety goals set forth in the Institute of Medicine's landmark To Err is Human[3] report, despite more than a decade of national, local, and regional efforts.[4] One way to reduce waste and improve patient safety is to eliminate practices of unproven benefit. Therapies or tests that may initially seem promising are often proven to be not only unhelpful but actually harmful. The recommendation of the US Preventive Services Task Force against routine screening for prostate specific antigen is an example of how a common test initially thought of as lifesaving actually increases harm.[5]
The American Board of Internal Medicine Foundation (ABIM‐F) recently announced the Choosing Wisely campaign. Through this campaign the Foundation encourages physicians, patients and other healthcare stakeholders to think and talk about medical tests and procedures that may be unnecessary.[6] The primary output of this challenge is the development of a list of 5 tests and or therapies that physicians and patients should question. The ABIM‐F approached different medical societies to develop these lists within their own specialties. The Society of Hospital Medicine (SHM) joined the Choosing Wisely campaign in April 2012, and agreed to develop a list of 5 therapies and tests for adult hospital medicine and pediatric hospital medicine. Here we present the contribution of the pediatric workgroup detailing the methodology and process for developing the list, as well as summarizing the evidence supporting each recommendation.
METHODS
In the spring of 2012, the pediatric committee of the SHM convened a workgroup of pediatric hospitalists to develop a top 5 list for the field. This workgroup was composed of experienced pediatric hospitalists representing diverse geographic locations of the United States and a mix of academic and nonacademic practice settings. The group, consisting of 4 women and 9 men, began by proposing candidate recommendations after discussion with colleagues at their different practice sites. The group was charged to maintain a focus on overuse practices that had a strong basis in evidence, were frequently encountered at their practice sites, and achieved significant consensus among their colleagues. Figure 1 shows the process map describing the method for the development of the pediatric recommendations. All workgroup participants were queried as to conflict of interest relevant to this work and none were identified.
Literature Review
After the generation of the initial top 20 list, 2 reviewers conducted independent literature searches in PubMed, MEDLINE, and the Cochrane Library on the proposed topics. The reviewers also conducted generic Internet searches. Key search terms included pediatric asthma, bronchiolitis, chest radiograph, systemic corticosteroids, gastroesophageal reflux disease (GERD), infant, child, acid suppression therapy, continuous pulse oximetry, pneumonia, gastroenteritis, viral testing, blood culture, and soft tissue infections. To ensure that the reviewers included all studies relevant to the searches, they utilized broad terms. The search included all literature published through 2012, and nonEnglish language publications were included in the search. Studies selected and included in the review were based upon common criteria including whether the article discussed an evaluation of efficacy and/or utility of treatment, included a pediatric population in the guidelines or study, reviewed the harm associated with the administration of a particular test or treatment, and explored the cost associated with the test or treatment.
The Delphi Panel
Members of the workgroup formed a Delphi panel except for 1 member (R.Q.) who served as the nonvoting moderator. The members of the Delphi panel considered the results of the literature search for each recommendation along with the collated feedback from hospitalist listserves as described in Figure 1. Each panel member received a voting instrument with the candidate tests and treatments for the first round of Delphi voting. The panel utilized a modified Delphi method or the RAND Corporation (RAND)/University of California at Los Angeles (UCLA) appropriateness method as described in previous publications of quality indicator development in pediatrics.[7] Each panelist scored the candidate tests and treatments and forwarded the scores to the moderator. Subsequently, all the members of the Delphi panel met through a conference call to carry out the second round of voting. The deidentified collated results of the first round of Delphi voting were made available and discussed during the call. The moderator collated the final results, and the final 5 recommendations were those that had the highest score after the second round of Delphi voting.
Volume and Costs
During deliberations, the committee took into account the prevalence and cost rankings of our most common pediatric inpatient diagnoses. This was done using the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Utilization Project (HCUP), specifically, the Kids' Inpatient Database (KID). HCUP includes the largest collection of longitudinal hospital care data in the United States, encompassing all‐payer discharge‐level information. We excluded normal newborn hospitalizations, and looked at the top 10 acute inpatient diagnoses in terms of both volume and aggregate costs.
RESULTS
The initial list of 20 candidate tests and treatments as well as the refined list of 11 recommendations can be found as electronic supplements to this publication (see Supporting Table 1 and Supporting Table 2 in the online version of this article). The format and language of the list of 11 recommendations were chosen to mesh with that typically used in the ABIM‐F Choosing Wisely campaign. During the Delphi panel, there was strong group consensus about combining items 1 and 2 (chest radiographs in asthma and bronchiolitis) into a single recommendation.
| Do not order chest radiographs in children with asthma or bronchiolitis. |
| Do not use bronchodilators in children with bronchiolitis. |
| Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. |
| Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. |
| Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. |
The top 5 recommendations based on the result of the second round of Delphi scoring are shown in Table 1 and described below along with a detailed evidence summary.
Do not order chest radiographs in children with asthma or bronchiolitis.
The National Heart and Lung Institute's guidelines for the management of asthma, published in 1987, recommend against routinely obtaining chest radiographs in patients with asthma or asthma exacerbations.[8] Supporting this recommendation are several studies that show a low overall yield when obtaining chest radiographs for wheezing patients.[9, 10, 11] Most relevant, studies that evaluated the clinical utility of radiographs in patients with asthma have demonstrated that they influence clinical management in less than 2% of cases.[12] A quality improvement project aimed at decreasing the rate of chest radiographs obtained in patients with asthma demonstrated that close to 60% of patients admitted to the hospital had chest radiographs performed, and that significant overall reductions can be achieved (45.3%28.9%, P=0.0005) without impacting clinical outcomes negatively.[13]
Similarly, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely obtaining radiographs during the evaluation for bronchiolitis.[14] Studies assessing the utility of chest x‐rays in these children demonstrate an even lower incidence of abnormalities (0.75%) and indicate that, despite this low incidence, physicians are more likely to treat with antibiotics when radiographs are obtained.[15] There is also evidence that chest radiographs in patients with bronchiolitis are not useful in predicting severity of illness.[16] Furthermore, cost‐effective analyses have demonstrated that omitting chest radiographs in bronchiolitis is actually cost‐effective, without compromising diagnostic accuracy.[17] In a recently published national benchmarking inpatient collaborative, Ralston et al. demonstrated that the majority of patients admitted to the hospital with bronchiolitis have chest radiographs performed at a rate of 64% (interquartile range [IQR], 54%81%).[18]
In both bronchiolitis and asthma, the elimination of unnecessary radiographs has the potential to decrease costs, reduce radiation exposure, and minimize the overuse of antibiotics that often occurs secondary to false positive results.
Do not use bronchodilators in children with bronchiolitis.
Ralston showed that 70% (IQR, 59%83%) of admitted bronchiolitis patients received bronchodilators with an average of 7.9 doses per patient (IQR, 4.69.8). National guidelines for bronchiolitis suggest a very limited role of bronchodilators in patients with bronchiolitis.[14] The first meta‐analyses of studies related to the question of ‐agonist efficacy in bronchiolitis were published in the late 1990s, revealing minimal or no treatment effects.[19, 20] Since then, further research has solidified these findings, and fairly definitive statements can be made based on a recent comprehensive meta‐analysis.[21] The pooled data do not show any effect on hospitalization rates, hospital length of stay, or other inpatient outcomes in bronchiolitis. They do show a small change in clinical scores documented in the outpatient setting, though these scores have not correlated with any detectable difference in outcomes. Routine use of ‐agonists in the inpatient setting has no proven benefit, and given the large amount of consistent data, there is no compelling reason for further study of this therapy in the inpatient setting.
Epinephrine, a combined ‐ and ‐agonist, has been extensively evaluated in bronchiolitis as well. Like albuterol, epinephrine has been reported to have no effect on hospital length of stay in bronchiolitis.[22] The issue of admission rates after epinephrine is complicated by 1 very large study that combined epinephrine with dexamethasone and reported a decreased admission rate, though only at 7 days after therapy; however, this effect was nullified after adjustment for multiple comparisons.[23] When the end point is improvement of respiratory scores, epinephrine may perform better than albuterol in studies where they are directly compared; however, there is no evidence that repeated usage of epinephrine has any impact on any clinical outcome for inpatients.[24, 25]
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection
In their summary of evidence, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely using systemic corticosteroids for infants with bronchiolitis.[14] The previously reference bronchiolitis benchmarking study demonstrated that admitted patients received steroids at a rate of 21% (IQR, 14%26%). The poor efficacy of corticosteroids in children with bronchiolitis under 2 years of age is well demonstrated in the literature. A large, blinded, randomized, controlled study compared systemic oral corticosteroids to placebo in hospitalized children 10 months to 6 years of age with viral wheezing.[26] This study showed no benefit of corticosteroids over placebo in length of stay or parental report of symptoms 1 week later. In the study, a subanalysis of children with eczema and family history of asthma also demonstrated no benefit of systemic corticosteroids. Large systematic reviews further argue that there is no effect of corticosteroids on the likelihood of admission or length of stay in infants with bronchiolitis.[27, 28] One 4‐armed prospective study of children 6 weeks to 12 months of age found no efficacy of dexamethasone over placebo.[23] There was modest benefit of dexamethasone in conjunction with racemic epinephrine; however, this benefit disappeared after adjustment for multiple comparisons. Three smaller studies showing benefit of systemic corticosteroids, however, were highly problematic. They have included older children, were retrospective, or demonstrated inconsistent results.[29, 30] A smaller study showed benefit for children over 2 years of age, but none for children under 2 years of age.[31] Premature infants are at increased risk of asthma, which typically responds well to corticosteroids as these children get older. However, a retrospective study of premature infants under 2 years of age with bronchiolitis demonstrated no association between corticosteroid use and length of stay, even in the subset of premature infants responding to albuterol.[32]
Systemic corticosteroid use in children is not harmless. Children under 2 years of age are especially vulnerable to the decreased growth velocity seen as a side effect of systemic corticosteroids.[33] Corticosteroids may also negatively impact the course of infectious illness. For instance, in children hospitalized with pneumonia but not receiving ‐agonists (ie, patients who are unlikely to have asthma), length of stay is prolonged and readmission is higher in those who receive corticosteroids.[34]
Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.
From 2000 to 2005, the incidence of infants diagnosed with gastroeshopaheal reflux (GER) tripled (3.4%12.3%), and the use of proton pump inhibitors (PPIs) doubled (31.5%62.6%).[35] Patients diagnosed with GER and treated with antireflux medication incurred 1.8 times higher healthcare costs in 1 study compared to healthy controls.[36] Though common, the use of acid suppressive medications in infants lacks evidence for efficacy in the majority of the clinical scenarios in which they are prescribed.[37, 38] PPIs have failed to outperform placebo for typical infant reflux, which is generally developmental and not pathologic.[39, 40] Furthermore, prompted by findings in adults, multiple pediatric investigators have now catalogued the potential risks associated with acid blockade in children in multiple clinical settings. Specifically, increased risk of pneumonia has been documented in inpatients and outpatients, and increased risk of necrotizing enterocolitis and other serious infections have been documented in intensive care unit settings.[41] In the absence of data supporting efficacy and given the emerging data on risk, empiric acid suppression in infants with reflux is wasteful and potentially harmful.
Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
Pulse oximetry use has become widespread in the management of infants with bronchiolitis and likely accounts for the dramatic increase in bronchiolitis hospitalization rates in recent years.[14, 42, 43, 44, 45, 46, 47] Despite this increase in hospitalization rate, there was no change in mortality from bronchiolitis between 1979 and 1997.[48] The continuous monitoring of oxygen saturations in hospitalized infants with bronchiolitis may lead to overdiagnosis of hypoxemia and subsequent oxygen use that is of no apparent benefit to the child. Schroeder et al. demonstrated that 26% of a sample of infants hospitalized with bronchiolitis had a prolonged length of stay because of a perceived need for oxygen based on pulse oximetry readings.[43] Unger and Cunningham showed that the need for oxygen was the final determinant of length of stay in 58% of cases, and Cunningham and Murray suggested that using an oxygen saturation cutoff of 94% instead of 90% might increase the length of stay by 22 hours.[44, 49]
It has been previously shown that hypoxia is normative in infants. Healthy infants experience multiple episodes of SpO2 90% while sleeping.[50] This finding strengthens the notion that detection of low saturations in infants convalescing from bronchiolitis may simply reflect overdiagnosis. Among children with chronic severe asthma, who presumably have experienced episodes of hypoxia throughout childhood, there is no difference in school performance compared to healthy controls.[51]
The practice parameter on bronchiolitis from the American Academy of Pediatrics states: as the child's clinical course improves, continuous measurement of SpO2 is not routinely needed, which is a recommendation based on expert consensus.[14] There is at least one ongoing randomized trial comparing the use of continuous versus intermittent pulse oximetry in hospitalized infants with bronchiolitis who are weaned off oxygen (
DISCUSSION
Berwick and Hackbarth define overtreatment as: waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help themcare rooted in outmoded habits, supply‐driven behaviors, and ignoring science.[1] With this project, we tried to capture common clinical sources of waste in the inpatient pediatric setting. This is an inherently difficult project because of the absence of solid evidence to inform every decision point in medicine. Although there is always room for improvement in our evidence base, our group intentionally gravitated to areas where the evidence was robust.
The primary strength of this work is the use of the RAND/UCLA appropriateness method or modified Delphi method. Several publications have validated this methodology as a sound strategy to assess quality indicators and issues related to overuse.[7, 53] To our knowledge, we are the first group to report the use of this methodology to develop a list such as the list reported here.
There were some challenges inherent to this project that can be considered limitations of the work. One perceived limitation of our list is the heavy concentration on respiratory diagnoses, especially bronchiolitis and asthma. We do not feel this is a genuine limitation, as the recommendations were partly driven by volume and costs as assessed by the KID database. Among the top 10 acute inpatient diagnoses in pediatrics, respiratory diagnoses are the most common, including bronchiolitis, pneumonia, and asthma. Pneumonia or bronchiolitis has been the most common medical diagnosis in inpatient pediatrics for the past decade, and both are always in the top 10 for costs as well.[54] Thus, the impact of decreasing overuse for these conditions will be highly significant from a simple volume standpoint.
The primary limitation of this work is the lack of implementation strategies. Although the Choosing Wisely campaign has plans for dissemination of the lists, compliance with the recommendations may be suboptimal. Although the development process followed an accepted methodology, shortcomings include the lack of wide, local, multidisciplinary (including parents or caretakers) consultation. Other barriers to compliance with these recommendations exist. Despite evidence that bronchiolitis is a benign self‐limited disease that does not respond to bronchodilators and steroids, the drive to identify and correct all abnormalities, such as wheezing or low oxygen saturation in a nontoxic infant with bronchiolitis, seems to trump the obligation to do no harm in daily practice.[55] This behavior may result from pressure by patients, families, nurses, or peers and is deeply embedded in our medical culture, where action is preferred to inaction without full knowledge or consideration of risks. Doctors and nurses have become attached to the pulse oximeter, believing somehow that the number displayed is less subjective and holds more predictive value than careful evaluation of the patient's respiratory status. Other pressures, such as direct to consumer marketing have made acid reflux a household term that is easily treated with over‐the‐counter medications. Considerations of the care continuum will also serve as barriers. Chest x‐rays, for example, are frequently obtained prior to admission to the hospital before the hospitalist is involved.
To overcome these limitations, the study of individual and organizational adoption of innovation might be relevant. Though it is complex and often more descriptive than proscriptive, a few salient features have emerged. Champions and opinion leaders make a difference, local culture is dominant, social networking is important, simple innovations that can be trialed on a small scale are adaptable by the user and have observable benefits, are more likely to be adopted.[56] Fortunately, the top 5 list meets many of these criteria, but also faces the daunting challenges of inertia, lack of financial incentive, inability to break with old habits, and fear of lawsuits and perceived patient/parent dissatisfaction. Ongoing evaluation, feedback, and audit will be necessary to detect and sustain change.
CONCLUSION
We have identified 5 tests or therapies overused in inpatient general pediatrics. One goal of the Choosing Wisely campaign is to begin to change social norms related to physician behavior. We hope by asking clinicians to consider doing less for common conditions in inpatient pediatrics, that they will increasingly consider the known and unanticipated risks of any medical interventions they choose to use. Finally, we would like to encourage all pediatricians to embrace the idea of good stewardship and join us in prioritizing and addressing waste and overuse as important patient safety issues as well as threats to the sustainability of our healthcare system.
Acknowledgments
The authors thank Drs. Doug Carlson, James O'Callaghan, and Karen Smith from the Society of Hospital Medicine's Pediatric and Quality and Safety Committees for their support of this effort.
Disclosure: Nothing to report.
- , . Eliminating waste in US health care. JAMA. 2012;307:1513–1516.
- , , . Safely doing less: a missing component of the patient safety dialogue. Pediatrics. 2011;128:e1596–e1597.
- , , . To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- , , , , , . Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–2134.
- . Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–134.
- , . Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–1802.
- , , , et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523.
- National Asthma Education and Prevention Program. Expert panel report 3 (EPR‐3): guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120:S94–S138.
- , . The chest x‐ray and childhood acute asthma. Aust Clin Rev. 1993;13:153–156.
- , , , . Clinical factors associated with focal infiltrates in wheezing infants and toddlers. Clin Pediatr (Phila). 2000;39:387–393.
- , , , . Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila). 1999;38:395–399.
- , , , , , . Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009;124:e29–e36.
- , . Reduce the rads: a quality assurance project on reducing unnecessary chest X‐rays in children with asthma. J Paediatr Child Health. 2005;41:107–111.
- American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774–1793.
- , , , et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150:429–433.
- , , , et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011;100:e17–e23.
- , , , et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol. 2009;44:122–127.
- , , , et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network. J Hosp Med. 2013;8:25–30.
- , , , . Efficacy of bronchodilator therapy in bronchiolitis. A meta‐analysis. Arch Pediatr Adolesc Med. 1996;150:1166–1172.
- , . Efficacy of beta2‐agonists in bronchiolitis: a reappraisal and meta‐analysis. Pediatrics. 1997;100:233–239.
- , . Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;(12):CD001266.
- , , , et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.
- , , , et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360:2079–2089.
- , , , et al. A multicenter, randomized, double‐blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. 2003;349:27–35.
- , , , . A randomized, controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr. 2002;141:818–824.
- , , , et al. Oral prednisolone for preschool children with acute virus‐induced wheezing. N Engl J Med. 2009;360:329–338.
- , , , et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.
- , , , , . Systemic corticosteroids in infant bronchiolitis: a meta‐analysis. Pediatrics. 2000;105:E44.
- , , , . Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics. 1993;92:513–518.
- , , . Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial. Pediatrics. 1990;86:350–356.
- , , , , . Effect of a single oral dose of prednisolone in acute childhood asthma. Lancet. 1987;1:879–882.
- , , , , . The clinical management of preterm infants with bronchiolitis. Hosp Pediatr. 2013;3:244–250.
- , . Glucocorticoids and growth in asthmatic children. Pediatr Allergy Immunol. 1995;6:145–154.
- , , , , , . Adjunct corticosteroids in children hospitalized with community‐acquired pneumonia. Pediatrics. 2011;127:e255–e263.
- , , , , , . Pediatric gastroesophageal reflux disease and acid‐related conditions: trends in incidence of diagnosis and acid suppression therapy. J Med Econ. 2009;12:348–355.
- , , , , , . Healthcare costs of GERD and acid‐related conditions in pediatric patients, with comparison between histamine‐2 receptor antagonists and proton pump inhibitors. Curr Med Res Opin. 2009;25:2703–2709.
- , , , . Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120:946–949.
- , , , , . Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr. 2007;45:421–427.
- , , , , , . Efficacy of proton‐pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011;127:925–935.
- . Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Ann Pharmacother. 2010;44:572–576.
- . Are there risks associated with empric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013;3:16–23.
- , , , . Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003;111:e45–e51.
- , , , . Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. 2004;158:527–530.
- , . Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008;121:470–475.
- . Oxygen therapy for bronchiolitis. Pediatrics. 2007;120:686–687; author reply 687–688.
- , , , , , . Bronchiolitis‐associated hospitalizations among US children, 1980–1996. JAMA. 1999;282:1440–1446.
- , . Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010;125:342–349.
- , , , , . Bronchiolitis‐associated mortality and estimates of respiratory syncytial virus‐associated deaths among US children, 1979–1997. J Infect Dis. 2001;183:16–22.
- , . Observational study of two oxygen saturation targets for discharge in bronchiolitis. Arch Dis Child. 2012;97:361–363.
- , , , et al. Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life. J Pediatr. 2011;159:377–383.e1.
- , . The impact of severe asthma on schoolchildren. J Asthma. 1999;36:409–417.
- , . Multi‐center, randomized trial of pulse oximetry monitoring strategies for children hospitalized for bronchiolitis. Abstract presented at: ID Week 2012; October 2012; San Diego, CA.
- , , , . The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65:1133–1143.
- Agency for Healthcare Research and Quality. HCUPnet. Kids inpatient database 2009. Available at: http://hcupnet.ahrq.gov. Accessed November 6, 2012.
- , , . Too little? Too much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011;171:1582–1585.
- . How to implement change in clinical practice. Paediatr Respir Rev. 2003;4:340–346.
Overuse in medicine is a significant and under‐recognized problem. Don Berwick estimated that waste accounts for at least 20% of healthcare expenditures in the United States, with overtreatment as one of the largest categories.[1] A commentary by Schroeder et al. challenged pediatricians to incorporate this knowledge into our own patient safety and quality movement.[2] Recently published data suggest that we are far from achieving the patient safety goals set forth in the Institute of Medicine's landmark To Err is Human[3] report, despite more than a decade of national, local, and regional efforts.[4] One way to reduce waste and improve patient safety is to eliminate practices of unproven benefit. Therapies or tests that may initially seem promising are often proven to be not only unhelpful but actually harmful. The recommendation of the US Preventive Services Task Force against routine screening for prostate specific antigen is an example of how a common test initially thought of as lifesaving actually increases harm.[5]
The American Board of Internal Medicine Foundation (ABIM‐F) recently announced the Choosing Wisely campaign. Through this campaign the Foundation encourages physicians, patients and other healthcare stakeholders to think and talk about medical tests and procedures that may be unnecessary.[6] The primary output of this challenge is the development of a list of 5 tests and or therapies that physicians and patients should question. The ABIM‐F approached different medical societies to develop these lists within their own specialties. The Society of Hospital Medicine (SHM) joined the Choosing Wisely campaign in April 2012, and agreed to develop a list of 5 therapies and tests for adult hospital medicine and pediatric hospital medicine. Here we present the contribution of the pediatric workgroup detailing the methodology and process for developing the list, as well as summarizing the evidence supporting each recommendation.
METHODS
In the spring of 2012, the pediatric committee of the SHM convened a workgroup of pediatric hospitalists to develop a top 5 list for the field. This workgroup was composed of experienced pediatric hospitalists representing diverse geographic locations of the United States and a mix of academic and nonacademic practice settings. The group, consisting of 4 women and 9 men, began by proposing candidate recommendations after discussion with colleagues at their different practice sites. The group was charged to maintain a focus on overuse practices that had a strong basis in evidence, were frequently encountered at their practice sites, and achieved significant consensus among their colleagues. Figure 1 shows the process map describing the method for the development of the pediatric recommendations. All workgroup participants were queried as to conflict of interest relevant to this work and none were identified.
Literature Review
After the generation of the initial top 20 list, 2 reviewers conducted independent literature searches in PubMed, MEDLINE, and the Cochrane Library on the proposed topics. The reviewers also conducted generic Internet searches. Key search terms included pediatric asthma, bronchiolitis, chest radiograph, systemic corticosteroids, gastroesophageal reflux disease (GERD), infant, child, acid suppression therapy, continuous pulse oximetry, pneumonia, gastroenteritis, viral testing, blood culture, and soft tissue infections. To ensure that the reviewers included all studies relevant to the searches, they utilized broad terms. The search included all literature published through 2012, and nonEnglish language publications were included in the search. Studies selected and included in the review were based upon common criteria including whether the article discussed an evaluation of efficacy and/or utility of treatment, included a pediatric population in the guidelines or study, reviewed the harm associated with the administration of a particular test or treatment, and explored the cost associated with the test or treatment.
The Delphi Panel
Members of the workgroup formed a Delphi panel except for 1 member (R.Q.) who served as the nonvoting moderator. The members of the Delphi panel considered the results of the literature search for each recommendation along with the collated feedback from hospitalist listserves as described in Figure 1. Each panel member received a voting instrument with the candidate tests and treatments for the first round of Delphi voting. The panel utilized a modified Delphi method or the RAND Corporation (RAND)/University of California at Los Angeles (UCLA) appropriateness method as described in previous publications of quality indicator development in pediatrics.[7] Each panelist scored the candidate tests and treatments and forwarded the scores to the moderator. Subsequently, all the members of the Delphi panel met through a conference call to carry out the second round of voting. The deidentified collated results of the first round of Delphi voting were made available and discussed during the call. The moderator collated the final results, and the final 5 recommendations were those that had the highest score after the second round of Delphi voting.
Volume and Costs
During deliberations, the committee took into account the prevalence and cost rankings of our most common pediatric inpatient diagnoses. This was done using the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Utilization Project (HCUP), specifically, the Kids' Inpatient Database (KID). HCUP includes the largest collection of longitudinal hospital care data in the United States, encompassing all‐payer discharge‐level information. We excluded normal newborn hospitalizations, and looked at the top 10 acute inpatient diagnoses in terms of both volume and aggregate costs.
RESULTS
The initial list of 20 candidate tests and treatments as well as the refined list of 11 recommendations can be found as electronic supplements to this publication (see Supporting Table 1 and Supporting Table 2 in the online version of this article). The format and language of the list of 11 recommendations were chosen to mesh with that typically used in the ABIM‐F Choosing Wisely campaign. During the Delphi panel, there was strong group consensus about combining items 1 and 2 (chest radiographs in asthma and bronchiolitis) into a single recommendation.
| Do not order chest radiographs in children with asthma or bronchiolitis. |
| Do not use bronchodilators in children with bronchiolitis. |
| Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. |
| Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. |
| Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. |
The top 5 recommendations based on the result of the second round of Delphi scoring are shown in Table 1 and described below along with a detailed evidence summary.
Do not order chest radiographs in children with asthma or bronchiolitis.
The National Heart and Lung Institute's guidelines for the management of asthma, published in 1987, recommend against routinely obtaining chest radiographs in patients with asthma or asthma exacerbations.[8] Supporting this recommendation are several studies that show a low overall yield when obtaining chest radiographs for wheezing patients.[9, 10, 11] Most relevant, studies that evaluated the clinical utility of radiographs in patients with asthma have demonstrated that they influence clinical management in less than 2% of cases.[12] A quality improvement project aimed at decreasing the rate of chest radiographs obtained in patients with asthma demonstrated that close to 60% of patients admitted to the hospital had chest radiographs performed, and that significant overall reductions can be achieved (45.3%28.9%, P=0.0005) without impacting clinical outcomes negatively.[13]
Similarly, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely obtaining radiographs during the evaluation for bronchiolitis.[14] Studies assessing the utility of chest x‐rays in these children demonstrate an even lower incidence of abnormalities (0.75%) and indicate that, despite this low incidence, physicians are more likely to treat with antibiotics when radiographs are obtained.[15] There is also evidence that chest radiographs in patients with bronchiolitis are not useful in predicting severity of illness.[16] Furthermore, cost‐effective analyses have demonstrated that omitting chest radiographs in bronchiolitis is actually cost‐effective, without compromising diagnostic accuracy.[17] In a recently published national benchmarking inpatient collaborative, Ralston et al. demonstrated that the majority of patients admitted to the hospital with bronchiolitis have chest radiographs performed at a rate of 64% (interquartile range [IQR], 54%81%).[18]
In both bronchiolitis and asthma, the elimination of unnecessary radiographs has the potential to decrease costs, reduce radiation exposure, and minimize the overuse of antibiotics that often occurs secondary to false positive results.
Do not use bronchodilators in children with bronchiolitis.
Ralston showed that 70% (IQR, 59%83%) of admitted bronchiolitis patients received bronchodilators with an average of 7.9 doses per patient (IQR, 4.69.8). National guidelines for bronchiolitis suggest a very limited role of bronchodilators in patients with bronchiolitis.[14] The first meta‐analyses of studies related to the question of ‐agonist efficacy in bronchiolitis were published in the late 1990s, revealing minimal or no treatment effects.[19, 20] Since then, further research has solidified these findings, and fairly definitive statements can be made based on a recent comprehensive meta‐analysis.[21] The pooled data do not show any effect on hospitalization rates, hospital length of stay, or other inpatient outcomes in bronchiolitis. They do show a small change in clinical scores documented in the outpatient setting, though these scores have not correlated with any detectable difference in outcomes. Routine use of ‐agonists in the inpatient setting has no proven benefit, and given the large amount of consistent data, there is no compelling reason for further study of this therapy in the inpatient setting.
Epinephrine, a combined ‐ and ‐agonist, has been extensively evaluated in bronchiolitis as well. Like albuterol, epinephrine has been reported to have no effect on hospital length of stay in bronchiolitis.[22] The issue of admission rates after epinephrine is complicated by 1 very large study that combined epinephrine with dexamethasone and reported a decreased admission rate, though only at 7 days after therapy; however, this effect was nullified after adjustment for multiple comparisons.[23] When the end point is improvement of respiratory scores, epinephrine may perform better than albuterol in studies where they are directly compared; however, there is no evidence that repeated usage of epinephrine has any impact on any clinical outcome for inpatients.[24, 25]
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection
In their summary of evidence, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely using systemic corticosteroids for infants with bronchiolitis.[14] The previously reference bronchiolitis benchmarking study demonstrated that admitted patients received steroids at a rate of 21% (IQR, 14%26%). The poor efficacy of corticosteroids in children with bronchiolitis under 2 years of age is well demonstrated in the literature. A large, blinded, randomized, controlled study compared systemic oral corticosteroids to placebo in hospitalized children 10 months to 6 years of age with viral wheezing.[26] This study showed no benefit of corticosteroids over placebo in length of stay or parental report of symptoms 1 week later. In the study, a subanalysis of children with eczema and family history of asthma also demonstrated no benefit of systemic corticosteroids. Large systematic reviews further argue that there is no effect of corticosteroids on the likelihood of admission or length of stay in infants with bronchiolitis.[27, 28] One 4‐armed prospective study of children 6 weeks to 12 months of age found no efficacy of dexamethasone over placebo.[23] There was modest benefit of dexamethasone in conjunction with racemic epinephrine; however, this benefit disappeared after adjustment for multiple comparisons. Three smaller studies showing benefit of systemic corticosteroids, however, were highly problematic. They have included older children, were retrospective, or demonstrated inconsistent results.[29, 30] A smaller study showed benefit for children over 2 years of age, but none for children under 2 years of age.[31] Premature infants are at increased risk of asthma, which typically responds well to corticosteroids as these children get older. However, a retrospective study of premature infants under 2 years of age with bronchiolitis demonstrated no association between corticosteroid use and length of stay, even in the subset of premature infants responding to albuterol.[32]
Systemic corticosteroid use in children is not harmless. Children under 2 years of age are especially vulnerable to the decreased growth velocity seen as a side effect of systemic corticosteroids.[33] Corticosteroids may also negatively impact the course of infectious illness. For instance, in children hospitalized with pneumonia but not receiving ‐agonists (ie, patients who are unlikely to have asthma), length of stay is prolonged and readmission is higher in those who receive corticosteroids.[34]
Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.
From 2000 to 2005, the incidence of infants diagnosed with gastroeshopaheal reflux (GER) tripled (3.4%12.3%), and the use of proton pump inhibitors (PPIs) doubled (31.5%62.6%).[35] Patients diagnosed with GER and treated with antireflux medication incurred 1.8 times higher healthcare costs in 1 study compared to healthy controls.[36] Though common, the use of acid suppressive medications in infants lacks evidence for efficacy in the majority of the clinical scenarios in which they are prescribed.[37, 38] PPIs have failed to outperform placebo for typical infant reflux, which is generally developmental and not pathologic.[39, 40] Furthermore, prompted by findings in adults, multiple pediatric investigators have now catalogued the potential risks associated with acid blockade in children in multiple clinical settings. Specifically, increased risk of pneumonia has been documented in inpatients and outpatients, and increased risk of necrotizing enterocolitis and other serious infections have been documented in intensive care unit settings.[41] In the absence of data supporting efficacy and given the emerging data on risk, empiric acid suppression in infants with reflux is wasteful and potentially harmful.
Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
Pulse oximetry use has become widespread in the management of infants with bronchiolitis and likely accounts for the dramatic increase in bronchiolitis hospitalization rates in recent years.[14, 42, 43, 44, 45, 46, 47] Despite this increase in hospitalization rate, there was no change in mortality from bronchiolitis between 1979 and 1997.[48] The continuous monitoring of oxygen saturations in hospitalized infants with bronchiolitis may lead to overdiagnosis of hypoxemia and subsequent oxygen use that is of no apparent benefit to the child. Schroeder et al. demonstrated that 26% of a sample of infants hospitalized with bronchiolitis had a prolonged length of stay because of a perceived need for oxygen based on pulse oximetry readings.[43] Unger and Cunningham showed that the need for oxygen was the final determinant of length of stay in 58% of cases, and Cunningham and Murray suggested that using an oxygen saturation cutoff of 94% instead of 90% might increase the length of stay by 22 hours.[44, 49]
It has been previously shown that hypoxia is normative in infants. Healthy infants experience multiple episodes of SpO2 90% while sleeping.[50] This finding strengthens the notion that detection of low saturations in infants convalescing from bronchiolitis may simply reflect overdiagnosis. Among children with chronic severe asthma, who presumably have experienced episodes of hypoxia throughout childhood, there is no difference in school performance compared to healthy controls.[51]
The practice parameter on bronchiolitis from the American Academy of Pediatrics states: as the child's clinical course improves, continuous measurement of SpO2 is not routinely needed, which is a recommendation based on expert consensus.[14] There is at least one ongoing randomized trial comparing the use of continuous versus intermittent pulse oximetry in hospitalized infants with bronchiolitis who are weaned off oxygen (
DISCUSSION
Berwick and Hackbarth define overtreatment as: waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help themcare rooted in outmoded habits, supply‐driven behaviors, and ignoring science.[1] With this project, we tried to capture common clinical sources of waste in the inpatient pediatric setting. This is an inherently difficult project because of the absence of solid evidence to inform every decision point in medicine. Although there is always room for improvement in our evidence base, our group intentionally gravitated to areas where the evidence was robust.
The primary strength of this work is the use of the RAND/UCLA appropriateness method or modified Delphi method. Several publications have validated this methodology as a sound strategy to assess quality indicators and issues related to overuse.[7, 53] To our knowledge, we are the first group to report the use of this methodology to develop a list such as the list reported here.
There were some challenges inherent to this project that can be considered limitations of the work. One perceived limitation of our list is the heavy concentration on respiratory diagnoses, especially bronchiolitis and asthma. We do not feel this is a genuine limitation, as the recommendations were partly driven by volume and costs as assessed by the KID database. Among the top 10 acute inpatient diagnoses in pediatrics, respiratory diagnoses are the most common, including bronchiolitis, pneumonia, and asthma. Pneumonia or bronchiolitis has been the most common medical diagnosis in inpatient pediatrics for the past decade, and both are always in the top 10 for costs as well.[54] Thus, the impact of decreasing overuse for these conditions will be highly significant from a simple volume standpoint.
The primary limitation of this work is the lack of implementation strategies. Although the Choosing Wisely campaign has plans for dissemination of the lists, compliance with the recommendations may be suboptimal. Although the development process followed an accepted methodology, shortcomings include the lack of wide, local, multidisciplinary (including parents or caretakers) consultation. Other barriers to compliance with these recommendations exist. Despite evidence that bronchiolitis is a benign self‐limited disease that does not respond to bronchodilators and steroids, the drive to identify and correct all abnormalities, such as wheezing or low oxygen saturation in a nontoxic infant with bronchiolitis, seems to trump the obligation to do no harm in daily practice.[55] This behavior may result from pressure by patients, families, nurses, or peers and is deeply embedded in our medical culture, where action is preferred to inaction without full knowledge or consideration of risks. Doctors and nurses have become attached to the pulse oximeter, believing somehow that the number displayed is less subjective and holds more predictive value than careful evaluation of the patient's respiratory status. Other pressures, such as direct to consumer marketing have made acid reflux a household term that is easily treated with over‐the‐counter medications. Considerations of the care continuum will also serve as barriers. Chest x‐rays, for example, are frequently obtained prior to admission to the hospital before the hospitalist is involved.
To overcome these limitations, the study of individual and organizational adoption of innovation might be relevant. Though it is complex and often more descriptive than proscriptive, a few salient features have emerged. Champions and opinion leaders make a difference, local culture is dominant, social networking is important, simple innovations that can be trialed on a small scale are adaptable by the user and have observable benefits, are more likely to be adopted.[56] Fortunately, the top 5 list meets many of these criteria, but also faces the daunting challenges of inertia, lack of financial incentive, inability to break with old habits, and fear of lawsuits and perceived patient/parent dissatisfaction. Ongoing evaluation, feedback, and audit will be necessary to detect and sustain change.
CONCLUSION
We have identified 5 tests or therapies overused in inpatient general pediatrics. One goal of the Choosing Wisely campaign is to begin to change social norms related to physician behavior. We hope by asking clinicians to consider doing less for common conditions in inpatient pediatrics, that they will increasingly consider the known and unanticipated risks of any medical interventions they choose to use. Finally, we would like to encourage all pediatricians to embrace the idea of good stewardship and join us in prioritizing and addressing waste and overuse as important patient safety issues as well as threats to the sustainability of our healthcare system.
Acknowledgments
The authors thank Drs. Doug Carlson, James O'Callaghan, and Karen Smith from the Society of Hospital Medicine's Pediatric and Quality and Safety Committees for their support of this effort.
Disclosure: Nothing to report.
Overuse in medicine is a significant and under‐recognized problem. Don Berwick estimated that waste accounts for at least 20% of healthcare expenditures in the United States, with overtreatment as one of the largest categories.[1] A commentary by Schroeder et al. challenged pediatricians to incorporate this knowledge into our own patient safety and quality movement.[2] Recently published data suggest that we are far from achieving the patient safety goals set forth in the Institute of Medicine's landmark To Err is Human[3] report, despite more than a decade of national, local, and regional efforts.[4] One way to reduce waste and improve patient safety is to eliminate practices of unproven benefit. Therapies or tests that may initially seem promising are often proven to be not only unhelpful but actually harmful. The recommendation of the US Preventive Services Task Force against routine screening for prostate specific antigen is an example of how a common test initially thought of as lifesaving actually increases harm.[5]
The American Board of Internal Medicine Foundation (ABIM‐F) recently announced the Choosing Wisely campaign. Through this campaign the Foundation encourages physicians, patients and other healthcare stakeholders to think and talk about medical tests and procedures that may be unnecessary.[6] The primary output of this challenge is the development of a list of 5 tests and or therapies that physicians and patients should question. The ABIM‐F approached different medical societies to develop these lists within their own specialties. The Society of Hospital Medicine (SHM) joined the Choosing Wisely campaign in April 2012, and agreed to develop a list of 5 therapies and tests for adult hospital medicine and pediatric hospital medicine. Here we present the contribution of the pediatric workgroup detailing the methodology and process for developing the list, as well as summarizing the evidence supporting each recommendation.
METHODS
In the spring of 2012, the pediatric committee of the SHM convened a workgroup of pediatric hospitalists to develop a top 5 list for the field. This workgroup was composed of experienced pediatric hospitalists representing diverse geographic locations of the United States and a mix of academic and nonacademic practice settings. The group, consisting of 4 women and 9 men, began by proposing candidate recommendations after discussion with colleagues at their different practice sites. The group was charged to maintain a focus on overuse practices that had a strong basis in evidence, were frequently encountered at their practice sites, and achieved significant consensus among their colleagues. Figure 1 shows the process map describing the method for the development of the pediatric recommendations. All workgroup participants were queried as to conflict of interest relevant to this work and none were identified.
Literature Review
After the generation of the initial top 20 list, 2 reviewers conducted independent literature searches in PubMed, MEDLINE, and the Cochrane Library on the proposed topics. The reviewers also conducted generic Internet searches. Key search terms included pediatric asthma, bronchiolitis, chest radiograph, systemic corticosteroids, gastroesophageal reflux disease (GERD), infant, child, acid suppression therapy, continuous pulse oximetry, pneumonia, gastroenteritis, viral testing, blood culture, and soft tissue infections. To ensure that the reviewers included all studies relevant to the searches, they utilized broad terms. The search included all literature published through 2012, and nonEnglish language publications were included in the search. Studies selected and included in the review were based upon common criteria including whether the article discussed an evaluation of efficacy and/or utility of treatment, included a pediatric population in the guidelines or study, reviewed the harm associated with the administration of a particular test or treatment, and explored the cost associated with the test or treatment.
The Delphi Panel
Members of the workgroup formed a Delphi panel except for 1 member (R.Q.) who served as the nonvoting moderator. The members of the Delphi panel considered the results of the literature search for each recommendation along with the collated feedback from hospitalist listserves as described in Figure 1. Each panel member received a voting instrument with the candidate tests and treatments for the first round of Delphi voting. The panel utilized a modified Delphi method or the RAND Corporation (RAND)/University of California at Los Angeles (UCLA) appropriateness method as described in previous publications of quality indicator development in pediatrics.[7] Each panelist scored the candidate tests and treatments and forwarded the scores to the moderator. Subsequently, all the members of the Delphi panel met through a conference call to carry out the second round of voting. The deidentified collated results of the first round of Delphi voting were made available and discussed during the call. The moderator collated the final results, and the final 5 recommendations were those that had the highest score after the second round of Delphi voting.
Volume and Costs
During deliberations, the committee took into account the prevalence and cost rankings of our most common pediatric inpatient diagnoses. This was done using the Agency for Healthcare Research and Quality's (AHRQ) Healthcare Utilization Project (HCUP), specifically, the Kids' Inpatient Database (KID). HCUP includes the largest collection of longitudinal hospital care data in the United States, encompassing all‐payer discharge‐level information. We excluded normal newborn hospitalizations, and looked at the top 10 acute inpatient diagnoses in terms of both volume and aggregate costs.
RESULTS
The initial list of 20 candidate tests and treatments as well as the refined list of 11 recommendations can be found as electronic supplements to this publication (see Supporting Table 1 and Supporting Table 2 in the online version of this article). The format and language of the list of 11 recommendations were chosen to mesh with that typically used in the ABIM‐F Choosing Wisely campaign. During the Delphi panel, there was strong group consensus about combining items 1 and 2 (chest radiographs in asthma and bronchiolitis) into a single recommendation.
| Do not order chest radiographs in children with asthma or bronchiolitis. |
| Do not use bronchodilators in children with bronchiolitis. |
| Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. |
| Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. |
| Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. |
The top 5 recommendations based on the result of the second round of Delphi scoring are shown in Table 1 and described below along with a detailed evidence summary.
Do not order chest radiographs in children with asthma or bronchiolitis.
The National Heart and Lung Institute's guidelines for the management of asthma, published in 1987, recommend against routinely obtaining chest radiographs in patients with asthma or asthma exacerbations.[8] Supporting this recommendation are several studies that show a low overall yield when obtaining chest radiographs for wheezing patients.[9, 10, 11] Most relevant, studies that evaluated the clinical utility of radiographs in patients with asthma have demonstrated that they influence clinical management in less than 2% of cases.[12] A quality improvement project aimed at decreasing the rate of chest radiographs obtained in patients with asthma demonstrated that close to 60% of patients admitted to the hospital had chest radiographs performed, and that significant overall reductions can be achieved (45.3%28.9%, P=0.0005) without impacting clinical outcomes negatively.[13]
Similarly, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely obtaining radiographs during the evaluation for bronchiolitis.[14] Studies assessing the utility of chest x‐rays in these children demonstrate an even lower incidence of abnormalities (0.75%) and indicate that, despite this low incidence, physicians are more likely to treat with antibiotics when radiographs are obtained.[15] There is also evidence that chest radiographs in patients with bronchiolitis are not useful in predicting severity of illness.[16] Furthermore, cost‐effective analyses have demonstrated that omitting chest radiographs in bronchiolitis is actually cost‐effective, without compromising diagnostic accuracy.[17] In a recently published national benchmarking inpatient collaborative, Ralston et al. demonstrated that the majority of patients admitted to the hospital with bronchiolitis have chest radiographs performed at a rate of 64% (interquartile range [IQR], 54%81%).[18]
In both bronchiolitis and asthma, the elimination of unnecessary radiographs has the potential to decrease costs, reduce radiation exposure, and minimize the overuse of antibiotics that often occurs secondary to false positive results.
Do not use bronchodilators in children with bronchiolitis.
Ralston showed that 70% (IQR, 59%83%) of admitted bronchiolitis patients received bronchodilators with an average of 7.9 doses per patient (IQR, 4.69.8). National guidelines for bronchiolitis suggest a very limited role of bronchodilators in patients with bronchiolitis.[14] The first meta‐analyses of studies related to the question of ‐agonist efficacy in bronchiolitis were published in the late 1990s, revealing minimal or no treatment effects.[19, 20] Since then, further research has solidified these findings, and fairly definitive statements can be made based on a recent comprehensive meta‐analysis.[21] The pooled data do not show any effect on hospitalization rates, hospital length of stay, or other inpatient outcomes in bronchiolitis. They do show a small change in clinical scores documented in the outpatient setting, though these scores have not correlated with any detectable difference in outcomes. Routine use of ‐agonists in the inpatient setting has no proven benefit, and given the large amount of consistent data, there is no compelling reason for further study of this therapy in the inpatient setting.
Epinephrine, a combined ‐ and ‐agonist, has been extensively evaluated in bronchiolitis as well. Like albuterol, epinephrine has been reported to have no effect on hospital length of stay in bronchiolitis.[22] The issue of admission rates after epinephrine is complicated by 1 very large study that combined epinephrine with dexamethasone and reported a decreased admission rate, though only at 7 days after therapy; however, this effect was nullified after adjustment for multiple comparisons.[23] When the end point is improvement of respiratory scores, epinephrine may perform better than albuterol in studies where they are directly compared; however, there is no evidence that repeated usage of epinephrine has any impact on any clinical outcome for inpatients.[24, 25]
Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection
In their summary of evidence, the Subcommittee on Diagnosis and Management of Bronchiolitis of the American Academy of Pediatrics recommends against routinely using systemic corticosteroids for infants with bronchiolitis.[14] The previously reference bronchiolitis benchmarking study demonstrated that admitted patients received steroids at a rate of 21% (IQR, 14%26%). The poor efficacy of corticosteroids in children with bronchiolitis under 2 years of age is well demonstrated in the literature. A large, blinded, randomized, controlled study compared systemic oral corticosteroids to placebo in hospitalized children 10 months to 6 years of age with viral wheezing.[26] This study showed no benefit of corticosteroids over placebo in length of stay or parental report of symptoms 1 week later. In the study, a subanalysis of children with eczema and family history of asthma also demonstrated no benefit of systemic corticosteroids. Large systematic reviews further argue that there is no effect of corticosteroids on the likelihood of admission or length of stay in infants with bronchiolitis.[27, 28] One 4‐armed prospective study of children 6 weeks to 12 months of age found no efficacy of dexamethasone over placebo.[23] There was modest benefit of dexamethasone in conjunction with racemic epinephrine; however, this benefit disappeared after adjustment for multiple comparisons. Three smaller studies showing benefit of systemic corticosteroids, however, were highly problematic. They have included older children, were retrospective, or demonstrated inconsistent results.[29, 30] A smaller study showed benefit for children over 2 years of age, but none for children under 2 years of age.[31] Premature infants are at increased risk of asthma, which typically responds well to corticosteroids as these children get older. However, a retrospective study of premature infants under 2 years of age with bronchiolitis demonstrated no association between corticosteroid use and length of stay, even in the subset of premature infants responding to albuterol.[32]
Systemic corticosteroid use in children is not harmless. Children under 2 years of age are especially vulnerable to the decreased growth velocity seen as a side effect of systemic corticosteroids.[33] Corticosteroids may also negatively impact the course of infectious illness. For instance, in children hospitalized with pneumonia but not receiving ‐agonists (ie, patients who are unlikely to have asthma), length of stay is prolonged and readmission is higher in those who receive corticosteroids.[34]
Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy.
From 2000 to 2005, the incidence of infants diagnosed with gastroeshopaheal reflux (GER) tripled (3.4%12.3%), and the use of proton pump inhibitors (PPIs) doubled (31.5%62.6%).[35] Patients diagnosed with GER and treated with antireflux medication incurred 1.8 times higher healthcare costs in 1 study compared to healthy controls.[36] Though common, the use of acid suppressive medications in infants lacks evidence for efficacy in the majority of the clinical scenarios in which they are prescribed.[37, 38] PPIs have failed to outperform placebo for typical infant reflux, which is generally developmental and not pathologic.[39, 40] Furthermore, prompted by findings in adults, multiple pediatric investigators have now catalogued the potential risks associated with acid blockade in children in multiple clinical settings. Specifically, increased risk of pneumonia has been documented in inpatients and outpatients, and increased risk of necrotizing enterocolitis and other serious infections have been documented in intensive care unit settings.[41] In the absence of data supporting efficacy and given the emerging data on risk, empiric acid suppression in infants with reflux is wasteful and potentially harmful.
Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen.
Pulse oximetry use has become widespread in the management of infants with bronchiolitis and likely accounts for the dramatic increase in bronchiolitis hospitalization rates in recent years.[14, 42, 43, 44, 45, 46, 47] Despite this increase in hospitalization rate, there was no change in mortality from bronchiolitis between 1979 and 1997.[48] The continuous monitoring of oxygen saturations in hospitalized infants with bronchiolitis may lead to overdiagnosis of hypoxemia and subsequent oxygen use that is of no apparent benefit to the child. Schroeder et al. demonstrated that 26% of a sample of infants hospitalized with bronchiolitis had a prolonged length of stay because of a perceived need for oxygen based on pulse oximetry readings.[43] Unger and Cunningham showed that the need for oxygen was the final determinant of length of stay in 58% of cases, and Cunningham and Murray suggested that using an oxygen saturation cutoff of 94% instead of 90% might increase the length of stay by 22 hours.[44, 49]
It has been previously shown that hypoxia is normative in infants. Healthy infants experience multiple episodes of SpO2 90% while sleeping.[50] This finding strengthens the notion that detection of low saturations in infants convalescing from bronchiolitis may simply reflect overdiagnosis. Among children with chronic severe asthma, who presumably have experienced episodes of hypoxia throughout childhood, there is no difference in school performance compared to healthy controls.[51]
The practice parameter on bronchiolitis from the American Academy of Pediatrics states: as the child's clinical course improves, continuous measurement of SpO2 is not routinely needed, which is a recommendation based on expert consensus.[14] There is at least one ongoing randomized trial comparing the use of continuous versus intermittent pulse oximetry in hospitalized infants with bronchiolitis who are weaned off oxygen (
DISCUSSION
Berwick and Hackbarth define overtreatment as: waste that comes from subjecting patients to care that, according to sound science and the patients' own preferences, cannot possibly help themcare rooted in outmoded habits, supply‐driven behaviors, and ignoring science.[1] With this project, we tried to capture common clinical sources of waste in the inpatient pediatric setting. This is an inherently difficult project because of the absence of solid evidence to inform every decision point in medicine. Although there is always room for improvement in our evidence base, our group intentionally gravitated to areas where the evidence was robust.
The primary strength of this work is the use of the RAND/UCLA appropriateness method or modified Delphi method. Several publications have validated this methodology as a sound strategy to assess quality indicators and issues related to overuse.[7, 53] To our knowledge, we are the first group to report the use of this methodology to develop a list such as the list reported here.
There were some challenges inherent to this project that can be considered limitations of the work. One perceived limitation of our list is the heavy concentration on respiratory diagnoses, especially bronchiolitis and asthma. We do not feel this is a genuine limitation, as the recommendations were partly driven by volume and costs as assessed by the KID database. Among the top 10 acute inpatient diagnoses in pediatrics, respiratory diagnoses are the most common, including bronchiolitis, pneumonia, and asthma. Pneumonia or bronchiolitis has been the most common medical diagnosis in inpatient pediatrics for the past decade, and both are always in the top 10 for costs as well.[54] Thus, the impact of decreasing overuse for these conditions will be highly significant from a simple volume standpoint.
The primary limitation of this work is the lack of implementation strategies. Although the Choosing Wisely campaign has plans for dissemination of the lists, compliance with the recommendations may be suboptimal. Although the development process followed an accepted methodology, shortcomings include the lack of wide, local, multidisciplinary (including parents or caretakers) consultation. Other barriers to compliance with these recommendations exist. Despite evidence that bronchiolitis is a benign self‐limited disease that does not respond to bronchodilators and steroids, the drive to identify and correct all abnormalities, such as wheezing or low oxygen saturation in a nontoxic infant with bronchiolitis, seems to trump the obligation to do no harm in daily practice.[55] This behavior may result from pressure by patients, families, nurses, or peers and is deeply embedded in our medical culture, where action is preferred to inaction without full knowledge or consideration of risks. Doctors and nurses have become attached to the pulse oximeter, believing somehow that the number displayed is less subjective and holds more predictive value than careful evaluation of the patient's respiratory status. Other pressures, such as direct to consumer marketing have made acid reflux a household term that is easily treated with over‐the‐counter medications. Considerations of the care continuum will also serve as barriers. Chest x‐rays, for example, are frequently obtained prior to admission to the hospital before the hospitalist is involved.
To overcome these limitations, the study of individual and organizational adoption of innovation might be relevant. Though it is complex and often more descriptive than proscriptive, a few salient features have emerged. Champions and opinion leaders make a difference, local culture is dominant, social networking is important, simple innovations that can be trialed on a small scale are adaptable by the user and have observable benefits, are more likely to be adopted.[56] Fortunately, the top 5 list meets many of these criteria, but also faces the daunting challenges of inertia, lack of financial incentive, inability to break with old habits, and fear of lawsuits and perceived patient/parent dissatisfaction. Ongoing evaluation, feedback, and audit will be necessary to detect and sustain change.
CONCLUSION
We have identified 5 tests or therapies overused in inpatient general pediatrics. One goal of the Choosing Wisely campaign is to begin to change social norms related to physician behavior. We hope by asking clinicians to consider doing less for common conditions in inpatient pediatrics, that they will increasingly consider the known and unanticipated risks of any medical interventions they choose to use. Finally, we would like to encourage all pediatricians to embrace the idea of good stewardship and join us in prioritizing and addressing waste and overuse as important patient safety issues as well as threats to the sustainability of our healthcare system.
Acknowledgments
The authors thank Drs. Doug Carlson, James O'Callaghan, and Karen Smith from the Society of Hospital Medicine's Pediatric and Quality and Safety Committees for their support of this effort.
Disclosure: Nothing to report.
- , . Eliminating waste in US health care. JAMA. 2012;307:1513–1516.
- , , . Safely doing less: a missing component of the patient safety dialogue. Pediatrics. 2011;128:e1596–e1597.
- , , . To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- , , , , , . Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–2134.
- . Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–134.
- , . Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–1802.
- , , , et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523.
- National Asthma Education and Prevention Program. Expert panel report 3 (EPR‐3): guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120:S94–S138.
- , . The chest x‐ray and childhood acute asthma. Aust Clin Rev. 1993;13:153–156.
- , , , . Clinical factors associated with focal infiltrates in wheezing infants and toddlers. Clin Pediatr (Phila). 2000;39:387–393.
- , , , . Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila). 1999;38:395–399.
- , , , , , . Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009;124:e29–e36.
- , . Reduce the rads: a quality assurance project on reducing unnecessary chest X‐rays in children with asthma. J Paediatr Child Health. 2005;41:107–111.
- American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774–1793.
- , , , et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150:429–433.
- , , , et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011;100:e17–e23.
- , , , et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol. 2009;44:122–127.
- , , , et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network. J Hosp Med. 2013;8:25–30.
- , , , . Efficacy of bronchodilator therapy in bronchiolitis. A meta‐analysis. Arch Pediatr Adolesc Med. 1996;150:1166–1172.
- , . Efficacy of beta2‐agonists in bronchiolitis: a reappraisal and meta‐analysis. Pediatrics. 1997;100:233–239.
- , . Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;(12):CD001266.
- , , , et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.
- , , , et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360:2079–2089.
- , , , et al. A multicenter, randomized, double‐blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. 2003;349:27–35.
- , , , . A randomized, controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr. 2002;141:818–824.
- , , , et al. Oral prednisolone for preschool children with acute virus‐induced wheezing. N Engl J Med. 2009;360:329–338.
- , , , et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.
- , , , , . Systemic corticosteroids in infant bronchiolitis: a meta‐analysis. Pediatrics. 2000;105:E44.
- , , , . Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics. 1993;92:513–518.
- , , . Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial. Pediatrics. 1990;86:350–356.
- , , , , . Effect of a single oral dose of prednisolone in acute childhood asthma. Lancet. 1987;1:879–882.
- , , , , . The clinical management of preterm infants with bronchiolitis. Hosp Pediatr. 2013;3:244–250.
- , . Glucocorticoids and growth in asthmatic children. Pediatr Allergy Immunol. 1995;6:145–154.
- , , , , , . Adjunct corticosteroids in children hospitalized with community‐acquired pneumonia. Pediatrics. 2011;127:e255–e263.
- , , , , , . Pediatric gastroesophageal reflux disease and acid‐related conditions: trends in incidence of diagnosis and acid suppression therapy. J Med Econ. 2009;12:348–355.
- , , , , , . Healthcare costs of GERD and acid‐related conditions in pediatric patients, with comparison between histamine‐2 receptor antagonists and proton pump inhibitors. Curr Med Res Opin. 2009;25:2703–2709.
- , , , . Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120:946–949.
- , , , , . Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr. 2007;45:421–427.
- , , , , , . Efficacy of proton‐pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011;127:925–935.
- . Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Ann Pharmacother. 2010;44:572–576.
- . Are there risks associated with empric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013;3:16–23.
- , , , . Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003;111:e45–e51.
- , , , . Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. 2004;158:527–530.
- , . Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008;121:470–475.
- . Oxygen therapy for bronchiolitis. Pediatrics. 2007;120:686–687; author reply 687–688.
- , , , , , . Bronchiolitis‐associated hospitalizations among US children, 1980–1996. JAMA. 1999;282:1440–1446.
- , . Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010;125:342–349.
- , , , , . Bronchiolitis‐associated mortality and estimates of respiratory syncytial virus‐associated deaths among US children, 1979–1997. J Infect Dis. 2001;183:16–22.
- , . Observational study of two oxygen saturation targets for discharge in bronchiolitis. Arch Dis Child. 2012;97:361–363.
- , , , et al. Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life. J Pediatr. 2011;159:377–383.e1.
- , . The impact of severe asthma on schoolchildren. J Asthma. 1999;36:409–417.
- , . Multi‐center, randomized trial of pulse oximetry monitoring strategies for children hospitalized for bronchiolitis. Abstract presented at: ID Week 2012; October 2012; San Diego, CA.
- , , , . The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65:1133–1143.
- Agency for Healthcare Research and Quality. HCUPnet. Kids inpatient database 2009. Available at: http://hcupnet.ahrq.gov. Accessed November 6, 2012.
- , , . Too little? Too much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011;171:1582–1585.
- . How to implement change in clinical practice. Paediatr Respir Rev. 2003;4:340–346.
- , . Eliminating waste in US health care. JAMA. 2012;307:1513–1516.
- , , . Safely doing less: a missing component of the patient safety dialogue. Pediatrics. 2011;128:e1596–e1597.
- , , . To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
- , , , , , . Temporal trends in rates of patient harm resulting from medical care. N Engl J Med. 2010;363:2124–2134.
- . Screening for prostate cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2012;157:120–134.
- , . Choosing wisely: helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801–1802.
- , , , et al. The quality of ambulatory care delivered to children in the United States. N Engl J Med. 2007;357:1515–1523.
- National Asthma Education and Prevention Program. Expert panel report 3 (EPR‐3): guidelines for the diagnosis and management of asthma—summary report 2007. J Allergy Clin Immunol. 2007;120:S94–S138.
- , . The chest x‐ray and childhood acute asthma. Aust Clin Rev. 1993;13:153–156.
- , , , . Clinical factors associated with focal infiltrates in wheezing infants and toddlers. Clin Pediatr (Phila). 2000;39:387–393.
- , , , . Chest radiographs in the pediatric emergency department for children < or = 18 months of age with wheezing. Clin Pediatr (Phila). 1999;38:395–399.
- , , , , , . Clinical predictors of pneumonia among children with wheezing. Pediatrics. 2009;124:e29–e36.
- , . Reduce the rads: a quality assurance project on reducing unnecessary chest X‐rays in children with asthma. J Paediatr Child Health. 2005;41:107–111.
- American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:1774–1793.
- , , , et al. Evaluation of the utility of radiography in acute bronchiolitis. J Pediatr. 2007;150:429–433.
- , , , et al. Incidence and predisposing factors for severe disease in previously healthy term infants experiencing their first episode of bronchiolitis. Acta Paediatr. 2011;100:e17–e23.
- , , , et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatr Pulmonol. 2009;44:122–127.
- , , , et al. Decreasing unnecessary utilization in acute bronchiolitis care: results from the value in inpatient pediatrics network. J Hosp Med. 2013;8:25–30.
- , , , . Efficacy of bronchodilator therapy in bronchiolitis. A meta‐analysis. Arch Pediatr Adolesc Med. 1996;150:1166–1172.
- , . Efficacy of beta2‐agonists in bronchiolitis: a reappraisal and meta‐analysis. Pediatrics. 1997;100:233–239.
- , . Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2010;(12):CD001266.
- , , , et al. Epinephrine for bronchiolitis. Cochrane Database Syst Rev. 2011;(6):CD003123.
- , , , et al. Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009;360:2079–2089.
- , , , et al. A multicenter, randomized, double‐blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med. 2003;349:27–35.
- , , , . A randomized, controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr. 2002;141:818–824.
- , , , et al. Oral prednisolone for preschool children with acute virus‐induced wheezing. N Engl J Med. 2009;360:329–338.
- , , , et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2010;(10):CD004878.
- , , , , . Systemic corticosteroids in infant bronchiolitis: a meta‐analysis. Pediatrics. 2000;105:E44.
- , , , . Controlled trial of oral prednisone in the emergency department treatment of children with acute asthma. Pediatrics. 1993;92:513–518.
- , , . Methylprednisolone therapy for acute asthma in infants and toddlers: a controlled clinical trial. Pediatrics. 1990;86:350–356.
- , , , , . Effect of a single oral dose of prednisolone in acute childhood asthma. Lancet. 1987;1:879–882.
- , , , , . The clinical management of preterm infants with bronchiolitis. Hosp Pediatr. 2013;3:244–250.
- , . Glucocorticoids and growth in asthmatic children. Pediatr Allergy Immunol. 1995;6:145–154.
- , , , , , . Adjunct corticosteroids in children hospitalized with community‐acquired pneumonia. Pediatrics. 2011;127:e255–e263.
- , , , , , . Pediatric gastroesophageal reflux disease and acid‐related conditions: trends in incidence of diagnosis and acid suppression therapy. J Med Econ. 2009;12:348–355.
- , , , , , . Healthcare costs of GERD and acid‐related conditions in pediatric patients, with comparison between histamine‐2 receptor antagonists and proton pump inhibitors. Curr Med Res Opin. 2009;25:2703–2709.
- , , , . Are we overprescribing antireflux medications for infants with regurgitation? Pediatrics. 2007;120:946–949.
- , , , , . Proton pump inhibitor utilization patterns in infants. J Pediatr Gastroenterol Nutr. 2007;45:421–427.
- , , , , , . Efficacy of proton‐pump inhibitors in children with gastroesophageal reflux disease: a systematic review. Pediatrics. 2011;127:925–935.
- . Effectiveness and safety of proton pump inhibitors in infantile gastroesophageal reflux disease. Ann Pharmacother. 2010;44:572–576.
- . Are there risks associated with empric acid suppression treatment of infants and children suspected of having gastroesophageal reflux disease? Hosp Pediatr. 2013;3:16–23.
- , , , . Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003;111:e45–e51.
- , , , . Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med. 2004;158:527–530.
- , . Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008;121:470–475.
- . Oxygen therapy for bronchiolitis. Pediatrics. 2007;120:686–687; author reply 687–688.
- , , , , , . Bronchiolitis‐associated hospitalizations among US children, 1980–1996. JAMA. 1999;282:1440–1446.
- , . Bronchiolitis: recent evidence on diagnosis and management. Pediatrics. 2010;125:342–349.
- , , , , . Bronchiolitis‐associated mortality and estimates of respiratory syncytial virus‐associated deaths among US children, 1979–1997. J Infect Dis. 2001;183:16–22.
- , . Observational study of two oxygen saturation targets for discharge in bronchiolitis. Arch Dis Child. 2012;97:361–363.
- , , , et al. Longitudinal assessment of hemoglobin oxygen saturation in preterm and term infants in the first six months of life. J Pediatr. 2011;159:377–383.e1.
- , . The impact of severe asthma on schoolchildren. J Asthma. 1999;36:409–417.
- , . Multi‐center, randomized trial of pulse oximetry monitoring strategies for children hospitalized for bronchiolitis. Abstract presented at: ID Week 2012; October 2012; San Diego, CA.
- , , , . The appropriateness method has acceptable reliability and validity for assessing overuse and underuse of surgical procedures. J Clin Epidemiol. 2012;65:1133–1143.
- Agency for Healthcare Research and Quality. HCUPnet. Kids inpatient database 2009. Available at: http://hcupnet.ahrq.gov. Accessed November 6, 2012.
- , , . Too little? Too much? Primary care physicians' views on US health care: a brief report. Arch Intern Med. 2011;171:1582–1585.
- . How to implement change in clinical practice. Paediatr Respir Rev. 2003;4:340–346.
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