Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department.

BACKGROUND AND OBJECTIVE: Clinical decision rules have reduced use of computed tomography (CT) to evaluate minor pediatric head injury in pediatric emergency departments (EDs). CT use remains high in community EDs, where the majority of children seek medical care. We sought to reduce the rate of CT scans used to evaluate pediatric head injury from 29% to 20% in a community ED. METHODS: We evaluated a quality improvement (QI) project in a community ED aimed at decreasing the use of head CT scans in children by implementing a validated head trauma prediction rule for traumatic brain injury. A multidisciplinary team identified key drivers of CT use and implemented decision aids to improve the use of prediction rules. The team identified and mitigated barriers. An affiliated children's hospital offered Maintenance of Certification credit and QI coaching to participants. We used statistical process control charts to evaluate the effect of the intervention on monthly CT scan rates and performed a Wald test of equivalence to compare preintervention and postintervention CT scan proportions. RESULTS: The baseline period (February 2013-July 2014) included 695 patients with a CT scan rate of 29.2% (95% confidence interval, 25.8%-32.6%). The postintervention period (August 2014-October 2015) included 651 patients with a CT scan rate of 17.4% (95% confidence interval, 14.5%-20.2%, P < .01). Barriers included targeting providers with variable pediatric experience and parental imaging expectations. CONCLUSIONS: We demonstrate that a Maintenance of Certification QI project sponsored by a children's hospital can facilitate evidence-based pediatric care and decrease the rate of unnecessary CT use in a community setting.

Prioritization of self-relevant perspectives in ageing.

This study investigated whether age-related sensitivity to self-relevance may benefit perspective taking, despite generally poorer perspective-taking capacity in older adults. In one perceptual matching task and two visual perspective-taking paradigms, we examined age differences in sensitivity to avatars representing self and other. In the matching task, older (60-83 years) and younger (18-20 years) adults were similarly biased toward the self- versus other-associated avatar. In the perspective-taking tasks, participants viewed these avatars within a virtual room. Task-relevant perspectives were either the same (i.e., congruent) or different (i.e., incongruent). In the 3PP-3PP task, both avatars were present, and participants adopted the perspective of one or the other. As in the matching task, young and old were similarly biased toward the self-associated avatar. However, age differences emerged in the 1PP-3PP task, which presented only one avatar per trial (varying between self and other), and participants responded based on their own first-person perspective or the avatar's. In summary, age modulated the ability to take perspectives primarily when participants' own first-person perspective was task relevant. Relative to younger adults, older adults prioritized the self (vs. other) avatar more during initial perspective computation and the first-person (vs. third-person) perspective more when selecting between incongruent perspectives.

Linking numeracy and asthma-related quality of life.

OBJECTIVE: To examine the correlation of numerical skills used in patients' self-management of asthma with asthma-related quality of life (AQOL). METHODS: Adults with moderate-severe asthma completed the Asthma Numeracy Questionnaire (ANQ), assessments of reading comprehension and self-efficacy, and the mini-Asthma Quality of Life Questionnaire (miniAQLQ). The numeracy-AQOL relationship was evaluated in the context of potential confounders (demographic variables) and mediators (e.g. income and self-efficacy), using tests of correlation then multivariable models to assess for confounders and mediators. RESULTS: 80 adults with moderate or severe asthma were evaluated. Mean ANQ score was 2.3+/-1.2 (range 0-4). ANQ was correlated with miniAQLQ (rho=0.24, p=0.03). This association was sustained (rho=0.27, p=0.02) when controlling for potential confounders significantly associated with AQOL (age, Latino ethnicity). The ANQ-miniAQLQ association was mediated by household income; the correlation was reduced by 81% when adjusting for income (rho=0.05, p=0.65). In contrast, self-efficacy less strongly mediated this association; the correlation was reduced by 26% when controlled for self-efficacy (rho=0.20, p=0.08). CONCLUSION: Numerical skills needed for asthma self-management influence AQOL primarily through their impact on income and, to a lesser extent, on self-efficacy. PRACTICE IMPLICATIONS: Adults with asthma will benefit from self-management instructions employing the simplest mathematical constructs whose understanding is confirmed by clinicians.

The relationship between pediatric residency program size and inpatient illness severity and diversity.

BACKGROUND: A critical component of pediatric residency training is exposure to diverse and challenging hospitalized patients, yet little is known about the differences in pediatric inpatient educational experiences across residencies. OBJECTIVE: To examine variations in inpatient illness severity and diagnostic diversity at the affiliated hospitals of small, medium, and large pediatric residencies. DESIGN: A retrospective analysis of hospital discharges among children aged 0 to 18 years (excluding newborns) in a sample of pediatric residency programs within the University HealthSystems Consortium. Main Outcomes of Interest The study compares the mean and median Diagnosis-Related Group (DRG) weights of hospital discharges (illness severity) as well as the percentage of discharges for the 5 most common diagnoses and the percentage of discharges for asthma (diagnostic diversity). RESULTS: There was no relationship between mean and median medical DRG weights and residency size (mean DRG weight: small, 0.89; medium, 0.86; and large, 0.85; small vs medium, P =.29; small vs large, P =.23). Larger programs had surgical patients with more severe illness (mean DRG weight, small, 2.11; medium, 2.08; and large, 2.47; small vs medium, P =.85; small vs large, P =.02) but less diagnostic diversity (small, 24.9%; medium, 25.9%; and large, 29.9%; small vs medium, P<.001; small vs large, P =.07). The proportion of medical discharges for asthma increased with residency size (small, 6.5%; medium, 7.4%; and large, 9.3%; small vs medium and large, P<.001). CONCLUSION: Large variations in inpatient illness severity and diagnostic diversity were seen across programs, but program size was found to be a poor indicator of inpatient learning opportunities.