Strengths, weaknesses, opportunities and threats of using AI-enabled technology in sleep medicine: a commentary.

Over the past few years, artificial intelligence (AI) has emerged as a powerful tool used to efficiently automate several tasks across multiple domains. Sleep medicine is perfectly positioned to leverage this tool due to the wealth of physiological signals obtained through sleep studies or sleep tracking devices and abundance of accessible clinical data through electronic medical records. However, caution must be applied when utilizing AI, due to intrinsic challenges associated with novel technology. The Artificial Intelligence in Sleep Medicine committee of the American Academy of Sleep Medicine (AASM) reviews advancements in AI within the sleep medicine field. In this article, the Artificial Intelligence in Sleep Medicine committee members provide a commentary on the scope of AI technology in sleep medicine. The commentary identifies three pivotal areas in sleep medicine which can benefit from AI technologies: clinical care, lifestyle management and population health management. This article provides a detailed analysis of the strengths, weaknesses, opportunities, and threats associated with using AI enabled technologies in each pivotal area. Finally, the article broadly reviews barriers and challenges associated with using AI enabled technologies and offers possible solutions.

Racial Inequities in Mortality Rate in Hospitalized Children.

BACKGROUND AND OBJECTIVES: Racial/ethnic inequities for inpatient mortality in children at a national level in the U.S. have not been explored. The objective of this study was to evaluate differences in inpatient mortality rate among different racial/ethnic groups, using the Kids' Inpatient Database. METHODS: A cross-sectional study of children of ages greater than 28 days and less than 21 years discharged during 2012 and 2016. Racial/ethnic groups - White, Black, Hispanic, Asian and Pacific Islander and Native Americans were analyzed in two cohorts, Cohort A (all discharges) and Cohort B (ventilated children). RESULTS: A total of 4,247,604 and 79,116 discharges were included in cohorts A and B, respectively. Univariate analysis showed that the inpatient mortality rate was highest among Asian and Pacific Islander children for both cohorts: A (0.47% [0.42-0.51]), B (10.9% [9.8-12.1]). Regression analysis showed that Asian and Pacific Islander and Black children had increased odds of inpatient mortality compared to White children: A (1.319 [1.162-1.496], 1.178 [1.105-1.257], respectively) and B (1.391 [1.199-1.613], 1.163 [1.079-1.255], respectively). Population-based hospital mortality was highest in Black children (1.17 per 10,000 children). CONCLUSIONS: Inpatient mortality rates are significantly higher in U.S. children of Asian and Pacific Islander and Black races compared to White children. U.S. population-based metrics such as hospitalization rate, ventilation rate, and hospital mortality rate are highest in Black children. Our data suggest that lower median household income alone may not account for a higher inpatient mortality rate. The causes and prevention of racial and ethnic inequities in hospitalized children need to be explored further.

Pediatric COVID-19 presenting as supraglottitis with vocal cord hypomobility.

In the United States, an estimated 7.3% of confirmed cases of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (COVID-19) are among persons aged less than 18 years. Data regarding clinical manifestations in this age group are still evolving. An upper airway predilection has been reported in children. We describe the case of a 15-year-old female with supraglottitis and unilateral hypomobility of vocal cord with concern for critical airway, associated with COVID-19. She was managed by a multidisciplinary team including critical care, infectious diseases, and otolaryngology. This report adds to the sparse but evolving body of literature on the clinical presentation of COVID-19 disease in children.

Integrating quality improvement into the ECHO model to improve care for children and youth with epilepsy.

OBJECTIVE: Project ECHO (Extension for Community Healthcare Outcomes), a telementoring program, utilizes lectures, case-based learning, and an "all teach-all learn" approach to increase primary care provider (PCP) knowledge/confidence in managing chronic health conditions. The American Academy of Pediatrics (AAP) Epilepsy and Comorbidities ECHO incorporated quality improvement (QI) methodology to create meaningful practice change, while increasing PCP knowledge/self-efficacy in epilepsy management using the ECHO model. METHODS: Monthly ECHO sessions (May 2018 to December 2018) included lectures, case presentations/discussion, and QI review. Pediatric practices were recruited through the AAP. Practices engaged in ECHO sessions and improvement activities including monthly Plan-Do-Study-Act cycles, team huddles, chart reviews, and QI coaching calls to facilitate practice change. They were provided resource toolkits with documentation templates, safety handouts, and medication side effects sheets. QI measures were selected from the American Academy of Neurology Measurement Set for Epilepsy. The AAP Quality Improvement Data Aggregator was used for data entry, run chart development, and tracking outcomes. Participants completed retrospective surveys to assess changes in knowledge and self-efficacy. RESULTS: Seven practices participated across five states. Average session attendance was 14 health professionals (range = 13-17). A total of 479 chart reviews demonstrated improvement in six of seven measures: health care transition (45.3%, P = .005), safety education (41.6%, P = .036), mental/behavioral health screening (32.2% P = .027), tertiary center referral (26.7%, not significant [n.s.]), antiseizure therapy side effects (23%, n.s.), and documenting seizure frequency (7.1%, n.s.); counseling for women of childbearing age decreased by 7.8%. SIGNIFICANCE: This project demonstrated that integrating QI into an ECHO model results in practice change and increases PCP knowledge/confidence/self-efficacy in managing epilepsy.

The Impact of Coronavirus Disease 2019 Pandemic on U.S. and Canadian PICUs.

OBJECTIVES: There are limited reports of the impact of the coronavirus disease 2019 pandemic focused on U.S. and Canadian PICUs. This hypothesis-generating report aims to identify the United States and Canadian trends of coronavirus disease 2019 in PICUs. DESIGN AND SETTING: To better understand how the coronavirus disease 2019 pandemic was affecting U.S. and Canadian PICUs, an open voluntary daily data collection process of Canadian and U.S. PICUs was initiated by Virtual Pediatric Systems, LLC (Los Angeles, CA; http://www.myvps.org) in mid-March 2020. Information was made available online to all PICUs wishing to participate. A secondary data collection was performed to follow-up on patients discharged from those PICUs reporting coronavirus disease 2019 positive patients. MEASUREMENTS AND MAIN RESULTS: To date, over 180 PICUs have responded detailing 530 PICU admissions requiring over 3,467 days of PICU care with 30 deaths. The preponderance of cases was in the eastern regions. Twenty-four percent of the patients admitted to the PICUs were over 18 years old. Fourteen percent of admissions were under 2 years old. Nearly 60% of children had comorbidities at admission with the average length of stay increasing by age and by severity of comorbidity. Advanced respiratory support was necessary during 67% of the current days of care, with 69% being conventional mechanical ventilation. CONCLUSIONS: PICUs have been significantly impacted by the pandemic. They have provided care not only for children but also adults. Patients with coronavirus disease 2019 have a high frequency of comorbidities, require longer stays, more ventilatory support than usual PICU admissions. These data suggest several avenues for further exploration.

National Sleep Foundation's updated sleep duration recommendations: final report.

OBJECTIVE: To make scientifically sound and practical recommendations for daily sleep duration across the life span. METHODS: The National Sleep Foundation convened a multidisciplinary expert panel (Panel) with broad representation from leading stakeholder organizations. The Panel evaluated the latest scientific evidence and participated in a formal consensus and voting process. Then, the RAND/UCLA Appropriateness Method was used to formulate sleep duration recommendations. RESULTS: The Panel made sleep duration recommendations for 9 age groups. Sleep duration ranges, expressed as hours of sleep per day, were designated as recommended, may be appropriate, or not recommended. Recommended sleep durations are as follows: 14-17 hours for newborns, 12-15 hours for infants, 11-14 hours for toddlers, 10-13 hours for preschoolers, 9-11 hours for school-aged children, and 8-10 hours for teenagers. Seven to 9 hours is recommended for young adults and adults, and 7-8 hours of sleep is recommended for older adults. The self-designated basis for duration selection and critical discussions are also provided. CONCLUSIONS: Consensus for sleep duration recommendations was reached for specific age groupings. Consensus using a multidisciplinary expert Panel lends robust credibility to the results. Finally, limitations and caveats of these recommendations are discussed.

National Sleep Foundation's sleep time duration recommendations: methodology and results summary.

OBJECTIVE: The objective was to conduct a scientifically rigorous update to the National Sleep Foundation's sleep duration recommendations. METHODS: The National Sleep Foundation convened an 18-member multidisciplinary expert panel, representing 12 stakeholder organizations, to evaluate scientific literature concerning sleep duration recommendations. We determined expert recommendations for sufficient sleep durations across the lifespan using the RAND/UCLA Appropriateness Method. RESULTS: The panel agreed that, for healthy individuals with normal sleep, the appropriate sleep duration for newborns is between 14 and 17 hours, infants between 12 and 15 hours, toddlers between 11 and 14 hours, preschoolers between 10 and 13 hours, and school-aged children between 9 and 11 hours. For teenagers, 8 to 10 hours was considered appropriate, 7 to 9 hours for young adults and adults, and 7 to 8 hours of sleep for older adults. CONCLUSIONS: Sufficient sleep duration requirements vary across the lifespan and from person to person. The recommendations reported here represent guidelines for healthy individuals and those not suffering from a sleep disorder. Sleep durations outside the recommended range may be appropriate, but deviating far from the normal range is rare. Individuals who habitually sleep outside the normal range may be exhibiting signs or symptoms of serious health problems or, if done volitionally, may be compromising their health and well-being.

Developing measures for pediatric quality: methods and experiences of the CHIPRA pediatric quality measures program grantees.

BACKGROUND: Monitoring quality is an important way of understanding how the health care system is serving children and families. The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) Pediatric Quality Measures Program (PQMP) funded efforts to develop and enhance measures to assess care for children and adolescents. We describe the processes used by the PQMP grantees to develop measures to assess the health care of children and adolescents in Medicaid and the Children's Health Insurance Program. METHODS: Key steps in the measures development process include identifying concepts, reviewing and synthesizing evidence, prioritizing concepts, defining how measures should be calculated, and measure testing. Stakeholder engagement throughout the process is critical. Case studies illustrate how PQMP grantees adapted the process to respond to the nature of measures they were charged to develop and overcome challenges encountered. RESULTS: PQMP grantees used varied approaches to measures development but faced common challenges, some specific to the field of pediatrics and some general to all quality measures. Major challenges included the limited evidence base, data systems difficult or unsuited for measures reporting, and conflicting stakeholder priorities. CONCLUSIONS: As part of the PQMP, grantees were able to explore innovative methods to overcome measurement challenges, including new approaches to building the evidence base and stakeholder consensus, integration of alternative data sources, and implementation of new testing methods. As a result, the PQMP has developed new quality measures for pediatric care while also building an infrastructure, expertise, and enhanced methods for measures development that promise to provide more relevant and meaningful tools for improving the quality of children's health care.

Considerations and evidence for an ADHD outcome measure.

OBJECTIVE: The 2011 American Academy of Pediatrics attention-deficit/hyperactivity disorder (ADHD) guideline emphasizes monitoring and measuring outcomes of children diagnosed with ADHD; however, recommendations for how to measure improvement are less clear. A long-term goal was to develop an outcome measure that assesses the quality of care for children with ADHD. As a first step in that process, we conducted a literature synthesis on the efficacy and effectiveness of guideline-recommended ADHD treatments on patient outcomes. METHODS: A literature search was conducted in PubMed according to PRISMA protocol and using MeSH terms. US Preventive Services Task Force (USPSTF) criteria were used to assess the level of evidence. Studies of interest were published after 2002 and assessed prospective ADHD improvement using recommended ADHD treatments. RESULTS: The systematic review resulted in 35 studies. According to USPSTF criteria, included studies were level I (n = 24), level II-1 (n = 1), and level II-2 (n = 10) and were rated as good (n = 20) or fair (n = 15). DSM-criteria-based rating scales were used most frequently to measure ADHD treatment outcomes. All included treatments resulted in ADHD improvement. Regardless of outcome measure, tool, or treatment type, symptom reduction and improvement were relatively large, with mean percentage reductions ranging from 20% to 86% on ADHD-Behavior Rating Scales scales, with only 1 study with <25% reduction. Effect sizes ranged from 0.15 to 4.57. CONCLUSIONS: On the basis of this literature review, a consistent pattern of improvement in pediatric ADHD patients' core symptoms emerged across studies, study designs, and recommended treatment approaches. This evidence supports the notion that an improvement of core symptoms within 1 year could satisfy the requirements of an effective outcome measure, which should be further investigated.

National quality measures for child mental health care: background, progress, and next steps.

OBJECTIVE: To review recent health policies related to measuring child health care quality, the selection processes of national child health quality measures, the nationally recommended quality measures for child mental health care and their evidence strength, the progress made toward developing new measures, and early lessons learned from these national efforts. METHODS: Methods used included description of the selection process of child health care quality measures from 2 independent national initiatives, the recommended quality measures for child mental health care, and the strength of scientific evidence supporting them. RESULTS: Of the child health quality measures recommended or endorsed during these national initiatives, only 9 unique measures were related to child mental health. CONCLUSIONS: The development of new child mental health quality measures poses methodologic challenges that will require a paradigm shift to align research with its accelerated pace.

Emerging medicolegal issues in the practice of pediatric sleep medicine.

With the rapid growth in the field of pediatric sleep medicine, health care providers need to be aware of several emerging legal issues that have the potential of impacting their clinical practice. This article provides an overview of emerging legal areas that might impact the practice of pediatric sleep medicine, and discusses civil liability emerging from medical malpractice, issues that health care providers must be aware of including issues related to providing care for minors, and newer areas that relate to legal prosecution for health care fraud as it may relate to violations of quality of care.

Making the case to improve quality and reduce costs in pediatric health care.

This article makes a case for the urgent need to improve health care quality and reduce costs. It provides an overview of the importance of the quality movement and the definition of quality, including the concept of clinical and operational quality. Some national drivers for quality improvement as well as drivers of escalating health care costs are discussed, along with the urgency of reducing health care costs. The link between quality and cost is reviewed using the concept of value in health care, which combines quality and cost in the same equation. The article ends with a discussion of future directions of the quality movement, including emerging concepts, such as risk-adjustment, shared responsibility for quality, measuring quality at the individual provider level, and evolving legal implications of the quality movement, as well as the concept of a shared savings model.

Databases for assessing the outcomes of the treatment of patients with congenital and paediatric cardiac disease--the perspective of critical care.

The development of databases to track the outcomes of children with cardiovascular disease has been ongoing for much of the last two decades, paralleled by the rise of databases in the intensive care unit. While the breadth of data available in national, regional and local databases has grown exponentially, the ability to identify meaningful measurements of outcomes for patients with cardiovascular disease is still in its early stages. In the United States of America, the Virtual Pediatric Intensive Care Unit Performance System (VPS) is a clinically based database system for the paediatric intensive care unit that provides standardized high quality, comparative data to its participants [https://portal.myvps.org/]. All participants collect information on multiple parameters: (1) patients and their stay in the hospital, (2) diagnoses, (3) interventions, (4) discharge, (5) various measures of outcome, (6) organ donation, and (7) paediatric severity of illness scores. Because of the standards of quality within the database, through customizable interfaces, the database can also be used for several applications: (1) administrative purposes, such as assessing the utilization of resources and strategic planning, (2) multi-institutional research studies, and (3) additional internal projects of quality improvement or research.In the United Kingdom, The Paediatric Intensive Care Audit Network is a database established in 2002 to record details of the treatment of all critically ill children in paediatric intensive care units of the National Health Service in England, Wales and Scotland. The Paediatric Intensive Care Audit Network was designed to develop and maintain a secure and confidential high quality clinical database of pediatric intensive care activity in order to meet the following objectives: (1) identify best clinical practice, (2) monitor supply and demand, (3) monitor and review outcomes of treatment episodes, (4) facilitate strategic healthcare planning, (5) quantify resource requirements, and (6) study the epidemiology of critical illness in children.Two distinct physiologic risk adjustment methodologies are the Pediatric Risk of Mortality Scoring System (PRISM), and the Paediatric Index of Mortality Scoring System 2 (PIM 2). Both Pediatric Risk of Mortality (PRISM 2) and Pediatric Risk of Mortality (PRISM 3) are comprised of clinical variables that include physiological and laboratory measurements that are weighted on a logistic scale. The raw Pediatric Risk of Mortality (PRISM) score provides quantitative measures of severity of illness. The Pediatric Risk of Mortality (PRISM) score when used in a logistic regression model provides a probability of the predicted risk of mortality. This predicted risk of mortality can then be used along with the rates of observed mortality to provide a quantitative measurement of the Standardized Mortality Ratio (SMR). Similar to the Pediatric Risk of Mortality (PRISM) scoring system, the Paediatric Index of Mortality (PIM) score is comprised of physiological and laboratory values and provides a quantitative measurement to estimate the probability of death using a logistic regression model.The primary use of national and international databases of patients with congenital cardiac disease should be to improve the quality of care for these patients. The utilization of common nomenclature and datasets by the various regional subspecialty databases will facilitate the eventual linking of these databases and the creation of a comprehensive database that spans conventional geographic and subspecialty boundaries.

Electronic healthcare data collection and pay-for-performance: translating theory into practice.

With insight grounded in his work for a national data collection consortium and as Vice President of Quality and Outcomes at the Children's Hospital of Wisconsin, the author connects the theory of pay-for-performance to the realities of its implementation. The author expands the Diagnosing the Data conversation by describing the challenges of collecting meaningful data and by addressing the potential legal issues that data use raises. Drawing on his national and local experience, the author concludes with suggestions for adopting data collection programs that are both clinically relevant and scientifically reliable.