Trends in Low-Value Care Among Children's Hospitals.

BACKGROUND AND OBJECTIVES: Longitudinal pediatric low-value care (LVC) trends are not well established. We used the Pediatric Health Information System LVC Calculator, which measures utilization of 30 nonevidenced-based services, to report 7-year LVC trends. METHODS: This retrospective cohort study applied the LVC Calculator to emergency department (ED) and hospital encounters from January 1, 2016, to December 31, 2022. We used generalized estimating equation models accounting for hospital clustering to assess temporal changes in LVC. RESULTS: There were 5 265 153 eligible ED encounters and 1 301 613 eligible hospitalizations. In 2022, of 21 LVC measures applicable to the ED cohort, the percentage of encounters with LVC had increased for 11 measures, decreased for 1, and remained unchanged for 9 as compared with 2016. Computed tomography for minor head injury had the largest increase (17%-23%; P < .001); bronchodilators for bronchiolitis decreased (22%-17%; P = .001). Of 26 hospitalization measures, LVC increased for 6 measures, decreased for 9, and was unchanged for 11. Inflammatory marker testing for pneumonia had the largest increase (23%-38%; P = .003); broad-spectrum antibiotic use for pneumonia had the largest decrease (60%-48%; P < .001). LVC remained unchanged or decreased for most medication and procedure measures, but remained unchanged or increased for most laboratory and imaging measures. CONCLUSIONS: LVC improved for a minority of services between 2016 and 2022. Trends were more favorable for therapeutic (medications and procedures) than diagnostic measures (imaging and laboratory studies). These data may inform prioritization of deimplementation efforts.

Promoting a Sleep-friendly Environment by Minimizing Overnight Room Entries.

Introduction: Despite its importance in illness recovery, the sleep of hospitalized children is frequently interrupted. This quality improvement intervention aimed to reduce overnight room entries by minimizing unnecessary interventions. Methods: This study occurred at a university-affiliated children's hospital on the hospital medicine services from March 26, 2021, to April 14, 2022. The intervention included order set changes and the implementation of a rounding checklist designed to address factors most closely associated with sleep disruption and overnight room entries. The outcome measure was overnight (10 pm to 6 am) room entries, counted using room entry sensors. Process measures reflected the intervention targets (overnight vital sign orders, medication administration, and intravenous fluid use). The method of analysis was statistical process control charting. Results: After identifying special cause variation, the average number of overnight room entries decreased from 8.1 to 6.8, a 16% decrease. This decrease corresponded with the implementation of a rounding checklist. However, there continued to be variability in average room entries, suggesting a process lacking ongoing stability. During this period, avoidance of overnight medications and intravenous fluid increased by 28% and 17%, respectively. Conclusions: Implementing a rounding checklist to a broad patient population decreased overnight room entries. However, future work is needed to better understand the factors associated with sustaining such an improvement.

Palivizumab Prophylaxis in Infants and Young Children at Increased Risk of Hospitalization for Respiratory Syncytial Virus Infection.

Guidance from the American Academy of Pediatrics (AAP) for the use of palivizumab prophylaxis against respiratory syncytial virus (RSV) was first published in a policy statement in 1998. AAP recommendations have been updated periodically to reflect the most recent literature regarding children at greatest risk of severe RSV disease. Since the last update in 2014, which refined prophylaxis guidance to focus on those children at greatest risk, data have become available regarding the seasonality of RSV circulation, the incidence and risk factors associated with bronchiolitis hospitalizations, and the potential effects of the implementation of prophylaxis recommendations on hospitalization rates of children with RSV infection. This technical report summarizes the literature review by the Committee on Infectious Diseases, supporting the reaffirmation of the 2014 AAP policy statement on palivizumab prophylaxis among infants and young children at increased risk of hospitalization for RSV infection. Review of publications since 2014 did not support a change in recommendations for palivizumab prophylaxis and continues to endorse the guidance provided in the 2021 Red Book.

Interventions Associated With Increased Nighttime Room Entries in General Medical Patients.

BACKGROUND AND OBJECTIVES: Sleep is vital to recovery from illness, yet it is frequently interrupted in the hospital setting. Existing literature relying on survey data identifies vitals, medications, and pulse oximetry as major disruptors to sleep. This study was designed to assess the degree to which these candidate sleep disruptors are associated with objective room entries. METHODS: Room entry sensors were placed on doors to 18 rooms on acute medical-surgical units at a tertiary academic center. The number of entries into rooms between 10 Pm and 6 Am were logged on patients admitted to hospital medicine services from March 2021 through February 2022. Medical records were reviewed to extract orders for vital sign frequency, medication timing, continuous pulse oximetry, and intravenous fluid use overnight. Negative binomial regression was used to evaluate associations. RESULTS: Room entry data were collected for 112 admissions and 192 patient-nights. There was an average of 7.8 room entries per patient-night. After adjustments for the other variables and for patients represented in multiple nights, vitals ordered every 4 hours were associated with a 1.3-fold increase in room entries (95% confidence interval 1.0-1.5; P = .013), as were medications scheduled during overnight hours (1.3; 95% confidence interval 1.0-1.5; P = .016). There was no association between room entries and continuous pulse oximetry use. After adjustment, there was also no association with administration of intravenous fluids. CONCLUSIONS: Vitals ordered every 4 hours and medications scheduled during sleep hours are independently associated with increased room entries and may be reasonable initial targets for quality improvement interventions designed to minimize nighttime disruptions.

How Routine are Routine Vital Signs?

BACKGROUND AND OBJECTIVES: Frequent measurement of vital signs has been associated with disruptions to sleep and increased nursing workload. Since vital signs are often measured at the same frequency regardless of patient acuity, there may be inappropriate prioritization of limited resources. We sought to understand what hospitalists report as the default frequency of routine vital sign measurement in hospitalized pediatric patients at academic institutions. METHODS: We surveyed pediatric hospital medicine leadership at Association of American Medical Colleges-affiliated medical schools on their perception of routine vital signs in general medicine inpatients. RESULTS: Survey requests were sent to individuals representing 140 unique hospitals. Responses were received from 74 hospitalists, representing a 53% response rate. Routine vitals were most commonly characterized as those collected every 4 hours (78%; 95% confidence interval, 67%-87%), though at least 1 in 5 hospitalists reported obtaining all or select vital signs (eg, blood pressure) less frequently. Strategies to decrease vital sign frequency varied. CONCLUSIONS: Our results suggest routine vital signs are not a normative concept across all patient populations in pediatrics. We further identify several conditions under which deviation from routines are sanctioned.

Behavioral and Psychological Aspects of the Physician Experience with Deimplementation.

INTRODUCTION: Deimplementation, or the structured elimination of non-evidence-based practices, faces challenges distinct from those associated with implementation efforts. These barriers may be related to intrinsic psychological factors, as perceptions and emotions surrounding the discontinuation of established practices appear to differ from those associated with practice adoption. This study aims to explore barriers and facilitators experienced by pediatric clinicians engaging in deimplementation projects. METHODS: We used behavioral economics concepts to inform our qualitative study design following a theory-informed inductive approach. We conducted semistructured interviews with participants from two national quality improvement collaboratives where the primary outcomes were deimplementation measures. Using purposeful sampling, we recruited project leaders at institutions in the top and bottom quartiles from within each collaborative. Finally, we conducted a thematic analysis using a combination of inductive and deductive coding. RESULTS: In total, we interviewed participants from 12 high-performing sites and 7 low-performing sites. Participants identified nine concepts associated with successful deimplementation practice and three psychological barriers that impacted behavior change: (1) loss, (2) fear, and (3) action bias. Participants further identified four overarching strategies for mitigating the identified psychological barriers, including (1) making allowance for nonconformism; (2) permission to change; (3) normalizing; and (4) reframing. CONCLUSION: There is potential for more effective deimplementation through the proactive incorporation of an awareness of specific psychological barriers of loss, fear, and action bias, as well as specific mitigation strategies to address the psychocognitive experience.

Association of Arterial Hyperoxia With Outcomes in Critically Ill Children: A Systematic Review and Meta-analysis.

Importance: Oxygen supplementation is a cornerstone treatment in pediatric critical care. Accumulating evidence suggests that overzealous use of oxygen, leading to hyperoxia, is associated with worse outcomes compared with patients with normoxia. Objectives: To evaluate the association of arterial hyperoxia with clinical outcome in critically ill children among studies using varied definitions of hyperoxia. Data Sources: A systematic search of EMBASE, MEDLINE, Cochrane Library, and ClinicalTrials.gov from inception to February 1, 2021, was conducted. Study Selection: Clinical trials or observational studies of children admitted to the pediatric intensive care unit that examined hyperoxia, by any definition, and described at least 1 outcome of interest. No language restrictions were applied. Data Extraction and Synthesis: The Meta-analysis of Observational Studies in Epidemiology guideline and Newcastle-Ottawa Scale for study quality assessment were used. The review process was performed independently by 2 reviewers. Data were pooled with a random-effects model. Main Outcomes and Measures: The primary outcome was 28-day mortality; this time was converted to mortality at the longest follow-up owing to insufficient studies reporting the initial primary outcome. Secondary outcomes included length of stay, ventilator-related outcomes, extracorporeal organ support, and functional performance. Results: In this systematic review, 16 studies (27 555 patients) were included. All, except 1 randomized clinical pilot trial, were observational cohort studies. Study populations included were post-cardiac arrest (n = 6), traumatic brain injury (n = 1), extracorporeal membrane oxygenation (n = 2), and general critical care (n = 7). Definitions and assessment of hyperoxia differed among included studies. Partial pressure of arterial oxygen was most frequently used to define hyperoxia and mainly by categorical cutoff. In total, 11 studies (23 204 patients) were pooled for meta-analysis. Hyperoxia, by any definition, showed an odds ratio of 1.59 (95% CI, 1.00-2.51; after Hartung-Knapp adjustment, 95% CI, 1.05-2.38) for mortality with substantial between-study heterogeneity (I2 = 92%). This association was also found in less heterogeneous subsets. A signal of harm was observed at higher thresholds of arterial oxygen levels when grouped by definition of hyperoxia. Secondary outcomes were inadequate for meta-analysis. Conclusions and Relevance: These results suggest that, despite methodologic limitations of the studies, hyperoxia is associated with mortality in critically ill children. This finding identifies the further need for prospective observational studies and importance to address the clinical implications of hyperoxia in critically ill children.

Effect of a Quality Improvement Bundle to Standardize the Use of Intravenous Fluids for Hospitalized Pediatric Patients: A Stepped-Wedge, Cluster Randomized Clinical Trial.

Importance: Given that hypotonic maintenance intravenous fluids (IVF) may cause hospital-acquired harm, in November 2018, the American Academy of Pediatrics released a clinical practice guideline recommending the use of isotonic IVF for patients aged 28 days to 18 years without contraindications. No recommendations were made regarding laboratory monitoring; however, unnecessary laboratory tests may contribute to health care waste and harm patients. Objective: To examine the effect of a quality improvement intervention bundle on (1) increasing the mean proportion of hours per hospital day with exclusive isotonic IVF use to at least 80% and (2) decreasing the mean proportion of hospital days with laboratory tests obtained. Design, Setting, and Participants: This stepped-wedge, cluster randomized clinical trial (Standardization of Fluids in Inpatient Settings [SOFI]) was sponsored by a national quality improvement collaborative and was conducted across 106 US pediatric hospitals. The SOFI intervention period was from September 2019 to March 2020. Interventions: Hospital sites were exposed to educational materials, a clinical algorithm and order set for IVF use, electronic medical record interventions to reduce laboratory testing, and "harms of overtesting" cards. Main Outcomes and Measures: Primary outcomes were mean proportion of hours per hospital day receiving exclusive isotonic IVF and mean proportion of hospital days with laboratory test values obtained. Secondary measures included total IVF duration per hospital day, daily patient weight measurement while receiving IVF, serum sodium testing, and adverse events. Baseline data were collected for 2 months; intervention period data, 7 months. Outcomes were analyzed using linear mixed-effects regression models. Results: A total of 106 hospitals were randomly assigned to 1 of 3 intervention start dates (wedges), and 100 hospitals (94%) completed the study. In total, 5215 hospitalizations were reviewed before the intervention, and 6724 hospitalizations were reviewed after the intervention. Prior to interventions, the mean (SD) proportion of hours per day with exclusive isotonic IVF use was 88.5% (31.7%). Interventions led to an absolute increase of 5.4% (95% CI, 3.9%-6.9%) above baseline in exclusive isotonic IVF use but did not change the proportion of hospital days during which a laboratory test value was obtained (estimated difference, 0.1%; 95% CI, -1.5% to 1.7%; P = .90), IVF use duration (estimated difference, -1.2%; 95% CI, -2.9% to 0.4%), serum sodium testing, or adverse events. There was an absolute increase of 4.4% (95% CI, 2.6%-6.2%) in the mean proportion of hospital days with a patient weight measurement while receiving IVF. Conclusions and Relevance: In this stepped-wedge, cluster randomized clinical trial, an intervention bundle significantly improved the use of isotonic maintenance IVF without a concomitant increase in adverse events or electrolyte testing. Further work is required to deimplement laboratory testing. Trial Registration: ClinicalTrials.gov Identifier: NCT03924674.

Development and Use of a Calculator to Measure Pediatric Low-Value Care Delivered in US Children's Hospitals.

Importance: The scope of low-value care in children's hospitals is poorly understood. Objective: To develop and apply a calculator of hospital-based pediatric low-value care to estimate prevalence and cost of low-value services. Design, Setting, and Participants: This cross-sectional study developed and applied a calculator of hospital-based pediatric low-value care to estimate the prevalence and cost of low-value services among 1 011 950 encounters reported in 49 US children's hospitals contributing to the Pediatric Health Information System (PHIS) database. To develop the calculator, a multidisciplinary stakeholder group searched existing pediatric low-value care measures and used an iterative process to identify and operationalize relevant hospital-based measures in the PHIS database. Children with an eligible encounter in 2019 were included in the calculator-applied analysis. Two cohorts were analyzed: an emergency department cohort (with encounters resulting in emergency department discharge) and a hospitalized cohort. Exposures: Eligible condition-specific hospital encounters. Main Outcomes and Measures: The proportion and volume of encounters in which low-value services were delivered and their associated standardized costs. Measures were ranked by those outcomes. Results: There were 1 011 950 encounters eligible for 1 or more of 30 calculator-included measures in 2019; encounters were incurred by 816 098 unique patients with a median age of 3 years (IQR, 1-8 years). In the emergency department cohort, low-value services delivered in the greatest percentage of encounters were Group A streptococcal testing among children younger than 3 years with pharyngitis (3679 of 9785 [37.6%]), computed tomography scan for minor head injury (7541 of 42 602 [17.7%]), and bronchodilators for treatment of bronchiolitis (8899 of 55 616 [16.0%]). In the hospitalized cohort, low-value care was most prevalent for broad-spectrum antibiotics in the treatment of community-acquired pneumonia (3406 of 5658 [60.2%]), acid suppression therapy for infants with esophageal reflux (3814 of 7507 of [50.8%]), and blood cultures for uncomplicated community-acquired pneumonia (2277 of 5823 [39.1%]). Measured low-value services generated nearly $17 million in total standardized cost. The costliest services in the emergency department cohort were computed tomography scan for abdominal pain (approximately $1.8 million) and minor head injury (approximately $1.5 million) and chest radiography for asthma (approximately $1.1 million). The costliest services in the hospitalized cohort were receipt of 2 or more concurrent antipsychotics (approximately $2.4 million), and chest radiography for bronchiolitis ($801 680) and asthma ($625 866). Conclusions and Relevance: This cross-sectional analysis found that low-value care for some pediatric services was prevalent and costly. Measuring receipt of low-value services across conditions informs prioritization of deimplementation efforts. Continued use of this calculator may establish trends in low-value care delivery.

Trends in Hospital Costs and Levels of Services Provided for Children With Bronchiolitis Treated in Children's Hospitals.

Importance: Increasing hospital costs for bronchiolitis have been associated with increasing patient complexity and mechanical ventilation. However, the associations of illness severity and diagnostic coding practices with bronchiolitis hospitalization costs have not been examined. Objective: To investigate the association of patient complexity, illness severity, and diagnostic coding practices with bronchiolitis hospitalization costs. Design, Setting, and Participants: This retrospective cross-sectional study included 385 883 infants aged 24 months or younger who were hospitalized with bronchiolitis at 39 hospitals in the Pediatric Health Information System database from January 1, 2010, to December 31, 2019. Exposure: Hospitalization for bronchiolitis. Main Outcomes and Measures: Inflation-adjusted standardized unit cost (expressed in dollar units) per hospitalization over time. A nested subgroup analysis was performed to further examine factors associated with changes in cost. Results: A total of 385 883 bronchiolitis hospitalizations were studied; the patients had a mean (SD) age of 7.5 (6.4) months and included 227 309 of 385 883 boys (58.9%) and 253 870 of 385 883 publicly insured patients (65.8%). Among patients hospitalized with bronchiolitis, the median standardized unit cost per hospitalization increased significantly during the study period (from $5636 [95% CI, $5558-$5714] in 2010 to $6973 [95% CI, $6915-$7030] in 2019; P < .001 for trend). Similar increases in cost were observed among subgroups of patients without a complex chronic condition and without the need for mechanical ventilation. However, costs for patients without a complex chronic condition or mechanical ventilation, who received care outside the intensive care unit did not change in an economically significant manner (from $4803 [95% CI, $4752-$4853] in 2010 to $4853 [95% CI, $4811-$4895] in 2019; P < .001 for trend), suggesting that intensive care unit use was a primary factor associated with cost increases. Substantial changes in coding practices were observed. Among patients hospitalized with bronchiolitis, 1.2% (95% CI, 1.1%-1.3%) were assigned an APR-DRG (All Patient Refined Diagnosis Related Group) for respiratory failure in 2010, which increased to 21.6% (95% CI, 21.2%-21.9%) in 2019 (P < .001 for trend). Increased costs and coding intensity were not accompanied by objective evidence of worsening illness severity. Conclusions and Relevance: This cross-sectional study suggests that hospitalized children with bronchiolitis are receiving costlier and more intensive care without objective evidence of increasing severity of illness. Changes in coding practices may complicate efforts to study trends in the use of health care resources using administrative data.

The Evolution of Quality Benchmarks for Bronchiolitis.

BACKGROUND AND OBJECTIVES: Evidence suggests that average performance on quality measures for bronchiolitis has been improving over time, but it is unknown whether optimal performance, as defined by Achievable Benchmarks of Care (ABCs), has also changed. Thus, we aimed to compare ABCs for established bronchiolitis quality measures between 2 consecutive time periods. As a secondary aim, we evaluated performance gaps, defined as the difference between median performance and ABCs, to identify measures that may benefit most from targeted quality initiatives. METHODS: We used hospital administrative data from the Pediatric Health Information System database to calculate ABCs and performance gaps for nonrecommended bronchiolitis tests and treatments in 2 groups (patients discharged from the emergency department [ED] and those hospitalized) over 2 time periods (2006-2014 and 2014-2019) corresponding to publication of national bronchiolitis guidelines. RESULTS: Substantial improvements were identified in ABCs for chest radiography (ED -8.8% [confidence interval (CI) -8.3% to -9.4%]; hospitalized -17.5% [CI -16.3% to -18.7%]), viral testing (hospitalized -14.6% [CI -13.5% to -15.7%]), antibiotic use (hospitalized -10.4% [CI -8.9% to -11.1%]), and bronchodilator use (ED -9.0% [CI -8.4% to -9.6%]). Viral testing (ED 11.5% [CI 10.9% to 12.1%]; hospitalized 21.5% [CI 19.6% to 23.4%]) and bronchodilator use (ED 13.8% [CI 12.8% to 14.8%]; hospitalized 22.8% [CI 20.6% to 25.1%]) demonstrated the largest performance gaps. CONCLUSIONS: Marked changes in ABCs over time for some bronchiolitis quality measures highlight the need to reevaluate improvement targets as practice patterns evolve. Measures with large performance gaps, such as bronchodilator use and viral testing, are recommended as targets for ongoing quality improvement initiatives.

Diagnostic Stewardship of Endotracheal Aspirate Cultures in a PICU.

BACKGROUND: Clinicians commonly obtain endotracheal aspirate cultures (EACs) in the evaluation of suspected ventilator-associated infections. However, bacterial growth in EACs does not distinguish bacterial colonization from infection and may lead to overtreatment with antibiotics. We describe the development and impact of a clinical decision support algorithm to standardize the use of EACs from ventilated PICU patients. METHODS: We monitored EAC use using a statistical process control chart. We compared the rate of EACs using Poisson regression and a quasi-experimental interrupted time series model and assessed clinical outcomes 1 year before and after introduction of the algorithm. RESULTS: In the preintervention year, there were 557 EACs over 5092 ventilator days; after introduction of the algorithm, there were 234 EACs over 3654 ventilator days (an incident rate of 10.9 vs 6.5 per 100 ventilator days). There was a 41% decrease in the monthly rate of EACs (incidence rate ratio [IRR]: 0.59; 95% confidence interval [CI] 0.51-0.67; P < .001). The interrupted time series model revealed a preexisting 2% decline in the monthly culture rate (IRR: 0.98; 95% CI 0.97-1.0; P = .01), immediate 44% drop (IRR: 0.56; 95% CI 0.45-0.70; P = .02), and stable rate in the postintervention year (IRR: 1.03; 95% CI 0.99-1.07; P = .09). In-hospital mortality, hospital length of stay, 7-day readmissions, and All Patients Refined Diagnosis Related Group severity and mortality scores were stable. The estimated direct cost savings was $26 000 per year. CONCLUSIONS: A clinical decision support algorithm standardizing EAC obtainment from ventilated PICU patients was associated with a sustained decline in the rate of EACs, without changes in mortality, readmissions, or length of stay.