RESUMO
Achieving excellent outcomes for patients with congenital heart disease requires coordinated effort and resources, and a need has developed for a structure that facilitates improvement and measures cardiac centers' progress toward optimal patient care. METHODS: The Heart Institute (HI) at Cincinnati Children's Hospital developed a Safety, Quality and Value (SQV) program to formalize the use of quality improvement (QI) methods with the goal of optimizing patient outcomes, experience, and value. The SQV program adopted a conceptual framework that considers aspects of structure, process, outcome, and value in defining quality metrics, and the program used the Model for Improvement to guide design and implementation of QI interventions. RESULTS: In the first four years since its inception, the SQV program facilitated important improvements in clinical outcomes, cost reductions, and safety. In addition to achieving measurable improvements, the creation of a formal SQV program fostered a culture of transparency and accountability, providing a new structure for how the HI shares clinical data among clinicians, hospital leadership, and the public. CONCLUSION: The creation of an infrastructure to strategically design, implement, and support QI efforts in a clinically busy pediatric acquired and congenital heart institute was successful in meeting its initial aims and is a promising approach and model for other programs.
Assuntos
Cardiopatias Congênitas/terapia , Melhoria de Qualidade/organização & administração , Custos e Análise de Custo , Humanos , Liderança , Cultura Organizacional , Avaliação de Processos e Resultados em Cuidados de Saúde , Segurança do Paciente , Satisfação do Paciente , Aprendizagem Baseada em Problemas/organização & administração , Melhoria de Qualidade/economia , Indicadores de Qualidade em Assistência à Saúde/organização & administração , Fluxo de TrabalhoRESUMO
Chronic kidney disease (CKD) is known to cause increased arterial stiffness, which is an important independent risk factor for adverse cardiovascular events. The purpose of this study was to assess the vascular properties of the aorta (AO) in a group of children with CKD using a noninvasive echocardiography (echo)-Doppler method. We studied 24 children with stages 2 through 5 CKD and 48 age-matched controls. Detailed echocardiographic assessment and echo-Doppler pulse wave velocity (PWV) was performed. Indices of arterial stiffness, including characteristic (Zc) and input (Zi) impedances, elastic pressure-strain modulus (Ep), and arterial wall stiffness index, were calculated. CKD patients underwent full nephrology assessment, and an iohexol glomerular filtration rate was performed, which allowed for accurate assignment of the CKD stage. CKD patients had greater median systolic blood pressure (114 vs. 110 mmHg; p < 0.04) and pulse pressure (51 vs. 40 mmHg; p < 0.001) compared with controls. PWV was similar between groups (358 vs. 344 cm s(-1); p = 0.759), whereas Zi (182 vs. 131 dyne s cm(-5); p < 0.001), Zc (146 vs. 138 dyne s cm(-5); p = 0.05), and Ep (280 vs. 230 mmHg; p < 0.02) were significantly greater in CKD than in controls. Although load-dependent measures of arterial stiffness were greater in non-dialysis dependent CKD patients, PWV was not increased compared with controls. This suggests that the increased arterial stiffness may not be permanent in these pediatric patients with kidney disease.
Assuntos
Aorta/diagnóstico por imagem , Aorta/fisiopatologia , Ecocardiografia Doppler/métodos , Insuficiência Renal Crônica/fisiopatologia , Rigidez Vascular , Adolescente , Estudos de Casos e Controles , Criança , Pré-Escolar , Estudos Transversais , Feminino , Taxa de Filtração Glomerular , Humanos , Masculino , Estudos Prospectivos , Fatores de RiscoRESUMO
OBJECTIVES: To identify and describe disparities in the provision of Emergency Department (ED) care in pediatric patients presenting with chest pain (CP). PATIENTS AND METHODS: Nationally representative data were drawn from the National Hospital Ambulatory Medical Care Survey (NHAMCS). All ED visits with a chief complaint of CP and age <19 years from 2002 to 2006 were analyzed. The primary outcome variable was "Anytest" performed (defined as any combination of complete blood count, electrocardiogram, and/or chest x-ray). Univariable analyses were performed with "Anytest" as the dependent variable and patient characteristics as independent variables. Multivariable analysis was performed using logistic regression with the same independent patient characteristics. RESULTS: Eight hundred eighteen pediatric CP visits representing 2 552 193 such visits nationwide were analyzed. Gender and metro/non-metro location were not associated with "Anytest." However, Caucasian patients (p = 0.01) and those with private insurance (p < 0.01) were significantly more likely to receive testing despite otherwise similar demographics and severity of illness. Multivariate analysis revealed race (p = 0.03), expected payer (p = 0.003), and triage level (p = 0.009) were significantly and independently associated with the frequency of testing performed. CONCLUSION: Disparities exist in the ED care of pediatric patients with CP. Identification of such variations is important and provides an opportunity for targeted interventions that ensure delivery of high-quality, cost-effective health care for children.
Assuntos
Dor no Peito/diagnóstico , Testes Diagnósticos de Rotina/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Adolescente , Negro ou Afro-Americano/estatística & dados numéricos , Contagem de Células Sanguíneas/estatística & dados numéricos , Dor no Peito/etnologia , Dor no Peito/etiologia , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Eletrocardiografia/estatística & dados numéricos , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Lactente , Recém-Nascido , Seguro Saúde/estatística & dados numéricos , Modelos Logísticos , Masculino , Razão de Chances , Valor Preditivo dos Testes , Radiografia Torácica/estatística & dados numéricos , Índice de Gravidade de Doença , Fatores de Tempo , Triagem/estatística & dados numéricos , Estados Unidos , População Branca/estatística & dados numéricosAssuntos
Ecocardiografia Transesofagiana , Cardiopatias Congênitas/diagnóstico por imagem , Adulto , Cateterismo Cardíaco , Cardiologia/educação , Criança , Competência Clínica , Contraindicações , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana/normas , Endocardite/diagnóstico por imagem , Bolsas de Estudo , Cardiopatias/diagnóstico por imagem , Humanos , Período IntraoperatórioRESUMO
OBJECTIVE: To compare the yield rate (YR) of echocardiography when evaluating children with suspected infectious endocarditis (IE) in both the actual clinical setting and in the hypothetic setting where strict clinical criteria are applied. Study design Medical records of 101 children undergoing echocardiography for suspected IE were reviewed. Echocardiograms with positive findings were identified and the actual diagnostic YR was calculated. With the use of clinical criteria proposed by von Reyn (VR), the probability of IE was retrospectively classified as (1) rejected, (2) possible, or (3) probable. Theoretic YR of echocardiography was calculated for each classification. RESULTS: The actual YR of echocardiography was 12% (12/101). The YR of echocardiography by VR class was 0% in rejected, 20% in possible, and 80% in probable cases (chi(2) = 55.1, P <.0001). Echocardiography did not change the probability of IE in any patient classified as rejected, but allowed reassignment of disease probability in a significant proportion of patients with possible or probable IE. CONCLUSIONS: The YR of echocardiography was significant when clinical probability of IE was intermediate-to-high, and low, with marginal clinical utility, when clinical probability was low. Strict pretest assessment of disease probability may lead to more effective utilization of echocardiography in this population.
Assuntos
Ecocardiografia , Endocardite Bacteriana/diagnóstico , Bactérias/isolamento & purificação , Criança , Ecocardiografia/estatística & dados numéricos , Ecocardiografia Transesofagiana , Endocardite Bacteriana/diagnóstico por imagem , Humanos , Probabilidade , Fatores de RiscoRESUMO
BACKGROUND: Although the videotape method (VTM) is commonly used to record and intrepret ecocardiographic images, many pediatric echocardiographers are considering acquiring to, interpreting from, and storing their images to digital disk using the single-beat digital acquisition method (SBM). The paucity of image redundancy using SBM should translate into improved laboratory efficiency compared with VTM, but hard data are lacking. The purpose of this study was to test the hypothesis that the time to acquire images to videotape using VTM and to disk using SBM would be the same for normal hearts and corresponding congenital heart diseases, but interpretation times would be shorter using SBM. METHODS: We measured the times to acquire and interpret 403 echocardiograms using standard VTM from Children's Hospital in Cincinnati, Ohio, and 352 echocardiograms acquired using SBM from Children's Hospital in San Diego, Calif. Diagnostic categories at each site included: (1) normal, (2) simple shunt or isolated valve disease, and (3) multiple-lesion disease. RESULTS: As a group, SBM echocardiograms included more hemodynamic measurements and took more time to acquire (P <.037), but less time to read (P <.001) than corresponding images acquired using VTM. Using SBM, it took more time to acquire normals and isolated valve or shunt lesions, whereas the average time to acquire multiple-lesion disease was the same using both VTM and SBM. With SBM, in contrast, interpretation times were significantly less for all corresponding diagnoses. CONCLUSION: SBM studies took longer to acquire because more hemodynamic measurements were acquired, but they were read in less time than corresponding VTM studies even though all videotapes were replayed in search fast-forward mode. Pediatric echocardiographers can increase their laboratory efficiency by converting from VTM to SBM.
Assuntos
Conversão Análogo-Digital , Ecocardiografia/economia , Gravação de Videoteipe/economia , Análise de Variância , Criança , Cardiopatias Congênitas/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico por imagem , Humanos , Interpretação de Imagem Assistida por Computador , Laboratórios Hospitalares/economia , Laboratórios Hospitalares/organização & administraçãoRESUMO
OBJECTIVE: To assess the cost-effectiveness of various strategies to evaluate heart murmurs in children. METHODS: We modeled 6 strategies to follow the initial examination by the pediatrician: (1) refer suspected pathologic murmurs to a cardiologist, (2) obtain a chest radiograph (CXR) and electrocardiogram (ECG) and refer suspected pathologic murmurs to a cardiologist, (3) refer suspected pathologic murmurs for an echocardiogram (ECHO), (4) obtain a CXR and ECG and refer suspected pathologic murmurs for an ECHO, (5) refer all patients with murmurs to a cardiologist, or (6) refer all patients with murmurs for an ECHO. RESULTS: The least effective was strategy 1, which detects 82% of pathologic murmurs at $72 per patient evaluated. Strategy 5 detects 95% of pathologic murmurs at $38,000 per additional case detected over strategy 1. The most effective, strategy 6, detects 100% of pathologic murmurs at $158,000 per additional case detected over strategy 5. Strategies 2, 3, and 4 were not cost-effective. The results were sensitive to the costs of cardiology referral and ECHO. CONCLUSIONS: Adding a CXR and ECG to the pediatrician's evaluation, or selectively referring directly to ECHO increases costs with little gain in accuracy. Given the current cost constraints present in health care, whether the optimal strategy involves referring to a cardiologist or obtaining an ECHO for all patients with murmurs depends on how much society should allocate to diagnose pathologic murmurs.