Measurement of Ambulatory Medication Errors in Children: A Scoping Review.

BACKGROUND AND OBJECTIVES: Children use most medications in the ambulatory setting where errors are infrequently intercepted. There is currently no established measure set for ambulatory pediatric medication errors. We have sought to identify the range of existing measures of ambulatory pediatric medication errors, describe the data sources for error measurement, and describe their reliability. METHODS: We performed a scoping review of the literature published since 1986 using PubMed, CINAHL, PsycINFO, Web of Science, Embase, and Cochrane and of grey literature. Studies were included if they measured ambulatory, including home, medication errors in children 0 to 26 years. Measures were grouped by phase of the medication use pathway and thematically by measure type. RESULTS: We included 138 published studies and 4 studies from the grey literature and identified 21 measures of medication errors along the medication use pathway. Most measures addressed errors in medication prescribing (n = 6), and administration at home (n = 4), often using prescription-level data and observation, respectively. Measures assessing errors at multiple phases of the medication use pathway (n = 3) frequently used error reporting databases and prospective measurement through direct in-home observation. We identified few measures of dispensing and monitoring errors. Only 31 studies used measurement methods that included an assessment of reliability. CONCLUSIONS: Although most available, reliable measures are too resource and time-intensive to assess errors at the health system or population level, we were able to identify some measures that may be adopted for continuous measurement and quality improvement.

Quality of Care for Youth Hospitalized for Suicidal Ideation and Self-Harm.

OBJECTIVE: To examine performance on quality measures for pediatric inpatient suicidal ideation/self-harm care, and whether performance is associated with reutilization. METHODS: Retrospective observational 8 hospital study of patients [N = 1090] aged 5 to 17 years hospitalized for suicidal ideation/self-harm between 9/1/14 and 8/31/16. Two medical records-based quality measures assessing suicidal ideation/self-harm care were evaluated, one on counseling caregivers regarding restricting access to lethal means and the other on communication between inpatient and outpatient providers regarding the follow-up plan. Multivariable logistic regression assessed associations between quality measure scores and 1) hospital site, 2) patient demographics, and 3) 30-day emergency department return visits and inpatient readmissions. RESULTS: Medical record documentation revealed that, depending on hospital site, 17% to 98% of caregivers received lethal means restriction counseling (mean 70%); inpatient-to-outpatient provider communication was documented in 0% to 51% of cases (mean 16%). The odds of documenting receipt of lethal means restriction counseling was higher for caregivers of female patients compared to caregivers of male patients (adjusted odds ratio [aOR] 1.51, 95% confidence interval [CI], 1.07-2.14). The odds of documenting inpatient-to-outpatient provider follow-up plan communication was lower for Black patients compared to White patients (aOR 0.45, 95% CI, 0.24-0.84). All-cause 30-day readmission was lower for patients with documented caregiver receipt of lethal means restriction counseling (aOR 0.48, 95% CI, 0.28-0.83). CONCLUSIONS: This study revealed disparities and deficits in the quality of care received by youth with suicidal ideation/self-harm. Providing caregivers lethal means restriction counseling prior to discharge may help to prevent readmission.

Hospital-Based Quality Measures for Pediatric Mental Health Care.

BACKGROUND AND OBJECTIVES: Patients with a primary mental health condition account for nearly 10% of pediatric hospitalizations nationally, but little is known about the quality of care provided for them in hospital settings. Our objective was to develop and test medical record-based measures used to assess quality of pediatric mental health care in the emergency department (ED) and inpatient settings. METHODS: We drafted an evidence-based set of pediatric mental health care quality measures for the ED and inpatient settings. We used the modified Delphi method to prioritize measures; 2 ED and 6 inpatient measures were operationalized and field-tested in 2 community and 3 children's hospitals. Eligible patients were 5 to 19 years old and diagnosed with psychosis, suicidality, or substance use from January 2012 to December 2013. We used bivariate and multivariate models to examine measure performance by patient characteristics and by hospital. RESULTS: Eight hundred and seventeen records were abstracted with primary diagnoses of suicidality (n = 446), psychosis (n = 321), and substance use (n = 50). Performance varied across measures. Among patients with suicidality, male patients (adjusted odds ratio: 0.27, P < .001) and African American patients (adjusted odds ratio: 0.31, P = .02) were less likely to have documentation of caregiver counseling on lethal means restriction. Among admitted suicidal patients, 27% had documentation of communication with an outside provider, with variation across hospitals (0%-38%; P < .001). There was low overall performance on screening for comorbid substance abuse in ED patients with psychosis (mean: 30.3). CONCLUSIONS: These new pediatric mental health care quality measures were used to identify sex and race disparities and substantial hospital variation. These measures may be useful for assessing and improving hospital-based pediatric mental health care quality.

Development of a Caregiver-Reported Experience Measure for Pediatric Hospital-to-Home Transitions.

OBJECTIVE: To develop and test a caregiver-reported experience measure for pediatric hospital-to-home transitions. DATA SOURCES/STUDY SETTING: Primary data were collected between 07/2014 and 05/2015 from caregivers within 2-8 weeks of their child's discharge from a tertiary care children's hospital. STUDY DESIGN/DATA COLLECTION: We used a step-wise approach to developing the measure that included drafting de novo survey items based on caregiver interviews (n = 18), pretesting items using cognitive interviews (n = 18), and pilot testing revised items among an independent sample of caregivers (n = 500). Item reduction statistics and confirmatory factor analysis (CFA) were performed on a test sample of the pilot data to refine the measure, followed by CFA on the validation sample to test the final measure model fit. PRINCIPAL FINDINGS: Of 46 initial survey items, 19 were removed after pretesting and 19 were removed after conducting item statistics and CFA. This resulted in an eight-item measure with two domains: transition preparation (four items) and transition support (four items). Survey items assess the quality of discharge instructions, access to needed support and resources, care coordination, and follow-up care. Practical fit indices demonstrated an acceptable model fit: χ2  = 28.3 (df = 19); root-mean-square error of approximation = 0.04; comparative fit index = 0.99; and Tucker-Lewis index = 0.98. CONCLUSIONS: An eight-item caregiver-reported experience measure to evaluate hospital-to-home transition outcomes in pediatric populations demonstrated acceptable content validity and psychometric properties.

Parents' information needs and influential factors when making decisions about TNF-α inhibitors.

BACKGROUND: Parents struggle when making treatment decisions for children with arthritis or other chronic conditions. Understanding their decision-making process is an essential step towards improving the decision-making experience. The objective of this study was to describe parents' information needs and the influences on their decision making about treatment with TNF-α inhibitors. METHODS: Survey domains were developed based on qualitative data and cognitive interviewing. We mailed the survey to parents of children with juvenile idiopathic arthritis or inflammatory bowel disease who had initiated treatment with TNF-α inhibitors in the prior 2 years. Data were analyzed using descriptive and non-parametric statistics. RESULTS: Survey response rate was 54.9 %. Each item had <2 % missing responses. Parents used an array of information sources when deciding about treatment with TNF-α inhibitors. Resources other than their child's specialist were most often used to increase confidence in parents' decisions or because they wanted to know more about other people's experiences being treated with TNF-α inhibitors, rather than due to a lack of understanding. All but two (cost and route of administration) of the influential decision factors were very or extremely important to the majority of participants with factors related to long-term side effects, treatment efficacy, and disease impact being most important. CONCLUSIONS: This study describes parents' information needs and influential factors in treatment decision making. Results suggest that future work should be aimed at helping families weigh risks and benefits, such as through decision support interventions, as well as developing opportunities to include people beyond the family and physician in the decision-making process.

Physicians' Perceptions of Shared Decision Making in Chronic Disease and Its Barriers and Facilitators.

This study assessed pediatric physicians' use of shared decision making (SDM) in 2 chronic conditions. Most physicians indicated that parent and adolescent trust and emotional readiness facilitated SDM, physicians' preferred approach to decision making. At the same time, they perceived few barriers, other than insurance limitations, to using SDM.

"On the scene": Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.

Cincinnati Children's Hospital Medical Center is transforming the way it cares for its patients by building a sophisticated model that focuses on accountable care across the continuum. As nurses from different parts of the organization, we act as change agents to develop an integrated structure built around the patient's needs, from prevention to self-management. We demonstrate how organizational structure, fluid staffing, professional practice, and healthy behaviors operationally catalyze the continuum of care, and how we utilize self-management, community-based programs, and care integration to change the outcome for our patients and families. While care coordination is taking on many forms in medical centers around the world, Cincinnati Children's is proud and passionate about sharing its best practices along the way.

Adolescent medicine: workforce trends and recommendations.

The academic successes of AM during the past 2 decades are marked by board certification, fellowship program accreditation, residency curricula creation, and the evolution of a remarkably respected scientific journal, the Journal of Adolescent Health. These same accomplishments have increased professional and public recognition of unmet population needs and the specialists who can help address them. The adolescent population is large, diverse, underserved, and characterized by increasingly complex medical and behavioral issues. Meeting their health care needs is a national priority. Primary care professionals who treat adolescents want and need adolescent-specific training in anticipatory guidance, screening, counseling, and management of common adolescent problems. A larger workforce of AM physicians is needed to provide this training, consult on complex medical and psychosocial issues when requested, and lead research efforts that will advance knowledge in the field. Developing this workforce will require improved recruitment into fellowship training; mentorship, policies, and resources that support trainee and faculty diversity; and articulation of the skills that define an AM physician.

Adolescents' needs for health care privacy.

OBJECTIVE: To understand adolescents' preferences for multidimensional aspects of privacy, including psychological, social, and physical, and confidentiality (informational privacy) in the health care setting. PATIENTS AND METHODS: Fifty-four adolescents with and without chronic illness participated in 12 focus groups composed of participants of the same age (11-14 or 15-19 years), gender, and health status. Health care preferences, including privacy and confidentiality, were discussed, and themes were determined. On the basis of a literature review, Burgoon's framework best represented participant feedback. The data were categorized as representations of informational, psychological, social, or physical privacy. RESULTS: Maintaining informational privacy (ie, keeping information confidential) was most salient to the adolescents. Younger adolescents were concerned with information being disclosed to others (ie, health care providers), whereas older adolescents worried more about information being disclosed to parents. Other privacy aspects (psychological, social, and physical) also were important. To protect psychological privacy, adolescents were cautious about revealing sensitive information for fear of being judged by providers. To protect social privacy, they were reluctant to talk with unfamiliar or multiple providers, and they did not want to discuss issues they perceived as unrelated to their health care. Adolescents who commented about physical privacy said that they thought about their physical safety during physical examinations, as well as their visibility to others, and said that they were more comfortable when examinations were performed by female rather than male providers. CONCLUSIONS: Adolescents value all aspects of privacy. Providers should address not only informational but also psychological, social, and physical privacy to improve the care of adolescent patients.

Family experiences with outpatient care: do adolescents and parents have the same perceptions?

PURPOSE: Providing healthcare for adolescents involves balancing parents' and adolescents' needs, and little research addressing, measuring, and achieving this balance has been conducted. A first step for healthcare providers toward achieving this balance is to understand the differences between parents and adolescents regarding perceptions of outpatient care experiences. This study was to explore and compare the experiences of care between parents and adolescents in a primary care setting. METHODS: As part of an institution-wide system to measure patient satisfaction, 170 pairs of adolescent patients aged 11-17.9 years and their parents/guardians who had an outpatient visit at a Teen Health Center located within a large pediatric hospital were interviewed by telephone using both closed- and open-ended questions. RESULTS: Overall, perceptions of care between adolescents and parents were very similar. However, adolescents reported less involvement in decisions about medical care and were less likely to receive understandable answers to questions. A qualitative analysis of responses to open-ended questions indicated that aspects of care important to both adolescents and parents are communication followed by interpersonal skills and technical competence. Parents and adolescents did not always view confidentiality in the same way. CONCLUSIONS: These findings suggest that more time should be spent focusing on the adolescents' needs concerning communication. Healthcare providers should focus on the adolescents' needs by involving them in decisions and providing understandable answers to questions. Both parents and adolescents should be surveyed to measure their experience of care, especially with respect to involvement in care decisions, communication, and confidentiality.

Improving access to pediatric subspecialty care: initial failures and lessons learned.

OBJECTIVES: We originally examined the effectiveness of strategies, proven successful in improving appointment availability in primary care, at a large tertiary-care academic medical center. We then sought to describe the reasons for the initial failure of these strategies. METHODS: Clinics participating in an access improvement initiative were matched to control clinics. Intervention clinics used a variety of techniques to improve access. Run charts were used to determine the impact of the interventions on appointment availability. Linear models, control charts, and other graphic displays were used to understand the relationship among supply, demand, and appointment availability. RESULTS: Access did not improve in intervention clinics. Neither a linear models approach nor the use of control charts resulted in a simple tool to help clinics better understand the relationship among supply, demand, and days to third next available appointment. However, the development of a single clinic chart that incorporated supply and demand, plus estimates of future supply and demand, made it clear that current supply would not be able to meet demand. This helped teams focus their efforts on improving supply. CONCLUSIONS: Use of detailed data-based tools to guide choices of interventions, coupled with new and explicit institutional expectations for physician attendance at clinics, appears to be a promising strategy for enhancing access.

Specialists understanding of the health care preferences of chronically ill adolescents.

PURPOSE: Doctors must understand patients' priorities to create an effective treatment partnership. Little is known about whether subspecialist pediatricians understand chronically ill adolescents' preferences. METHODS: A survey was conducted of 155 adolescents with chronic illnesses and 52 subspecialty physicians recruited from the same clinics of a children's hospital. Adolescents and physicians rated the importance that adolescents place on items relating to quality of care and physician-patient communication styles using a previously validated measure. RESULTS: For quality of care items, rank order correlation between physicians and patient responses was high (r = .63, p < .001) and both rated pain management items as most important. Physicians underestimated the importance adolescents placed on communicating with the physician as a friend and medical-technical aspects of care. For communication items, physicians' responses were significantly different than adolescents for 13 of 17 items. Except for three items pertaining to autonomy, physician and patient responses were in the same direction, but adolescent responses were less extreme. CONCLUSIONS: Physicians understood the importance of pain management to adolescents with chronic illnesses, but overestimated their desired level of autonomy. Asking adolescents for their preferences may be the first step in improving adolescents' experience of care.

Differences in disease outcomes between medicaid and privately insured children: possible health disparities in juvenile rheumatoid arthritis.

OBJECTIVE: To determine the relationship between health insurance status and disease outcome in children with juvenile rheumatoid arthritis (JRA). METHODS: JRA patients followed at a tertiary pediatric rheumatology center were assessed for the number of active joints and number of joints with limited range of motion. Disease activity, patient well-being, and pain were measured. Disability was assessed by the Childhood Health Assessment Questionnaire, health-related quality of life by the Pediatric Quality of Life Inventory (PedsQL) Generic Core Scale, and the PedsQL Rheumatology Module. Health care resource utilization was estimated based on the number of billing events for health services coded in administrative databases; these databases also provided information on patient health insurance status. Children insured by Medicaid or similar state programs for low-income families were considered to have Medicaid status. Disease outcomes of children with Medicaid status was compared with that of children with private health insurance. RESULTS: Forty (14%) of the 295 children with JRA had Medicaid status. Patients with Medicaid status were more often of nonwhite race (P < or = 0.04) and more frequently had a polyarticular or systemic disease course (P = 0.04) compared with other patients (n = 255). After correction for differences in disease duration, race, JRA onset, and JRA course between groups, children with Medicaid status continued to have significantly higher disability (P < 0.0003), and lower mean PedsQL Generic Core Scale scores (P < 0.05), while health resource utilization appeared similar between groups. CONCLUSION: Despite apparently similar health resource utilization and joint involvement, Medicaid status is associated with significantly lower health-related quality of life and higher disability in JRA.

Importance of organ dysfunction in determining hospital outcomes in children.

OBJECTIVES: To use measures of organ dysfunction derived from administrative data to assess clinical and economic outcomes in hospitalized children. STUDY DESIGN: We used the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic and procedure codes to evaluate organ dysfunction in all patients, excluding neonates, in the Healthcare Cost and Utilization Project Kids' Inpatient Database (KID). We adapted consensus clinical definitions to characterize organ dysfunction in terms of degree of impairment, type of organ system involvement, and number of dysfunctional organ systems. Univariate and multivariable models were constructed to determine the impact of organ dysfunction on in-hospital mortality and resource use. RESULTS: Patients with organ dysfunction (n=51,386) were younger and more often male than those without organ dysfunction, and they had significantly higher in-hospital mortality and resource use. Organ dysfunction, assessed in terms of degree, type, and number of dysfunctional organ systems, was consistently associated with all hospital outcomes. In multivariable models, types of organ system failures were most predictive of in-hospital mortality, whereas degree of organ system involvement allowed for a better assessment of resource use. CONCLUSIONS: Administrative data can be used to characterize multiple dimensions of organ dysfunction in children. Hospitalizations involving organ dysfunction are associated with significant clinical and economic consequences.