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.

Primary prevention of rheumatic fever in the 21st century: evaluation of a national programme.

Background: Acute rheumatic fever (ARF) has largely disappeared from high-income countries. However, in New Zealand (NZ) rates remain high in indigenous (Maori) and Pacific populations. In 2011, NZ launched an intensive and unparalleled primary Rheumatic Fever Prevention Programme (RFPP). We evaluated the impact of the school-based sore throat service component of the RFPP. Methods: The evaluation used national trends of all-age first episode ARF hospitalisation rates before (2009-11) and after (2012-16) implementation of the RFPP. A retrospective cohort study compared first-episode ARF incidence during time-not-exposed (23 093 207 person-days) and time-exposed (68 465 350 person-days) with a school-based sore throat service among children aged 5-12 years from 2012 to 2016. Results: Following implementation of the RFPP, the national ARF incidence rate declined by 28% from 4.0 per 100 000 [95% confidence interval (CI) 3.5-4.6] at baseline (2009-11) to 2.9 per 100 000 by 2016 (95% CI 2.4-3.4, P <0.01). The school-based sore throat service effectiveness overall was 23% [95% CI -6%-44%; rate ratio (RR) 0.77, 95% CI 0.56-1.06]. Effectiveness was greater in one high-risk region with high coverage (46%, 95% CI 16%-66%; RR 0.54, 95% CI 0.34-0.84). Conclusions: Population-based primary prevention of ARF through sore throat management may be effective in well-resourced settings like NZ where high-risk populations are geographically concentrated. Where high-risk populations are dispersed, a school-based primary prevention approach appears ineffective and is expensive.

Photodynamic therapy with chlorin-based photosensitizer at 405 nm: numerical, morphological, and clinical study.

Employment of chlorin-based photosensitizers (PSs) provides additional advantages to photodynamic therapy (PDT) due to absorption peak around 405 nm allowing for superficial impact and efficient antimicrobial therapy. We report on the morphological and clinical study of the efficiency of PDT at 405 nm employing chlorin-based PS. Numerical studies demonstrated difference in the distribution of absorbed dose at 405 nm in comparison with traditionally employed wavelength of 660 nm and difference in the in-depth absorbed dose distribution for skin and mucous tissues. Morphological study was performed at the inner surface of rabbit ear with histological examinations at different periods after PDT procedure. Animal study revealed tissue reaction to PDT consisting in edema manifested most in 3 days after the procedure and neoangiogenesis. OCT diagnostics was confirmed by histological examination. Clinical study included antimicrobial PDT of pharynx chronic inflammatory diseases. It revealed no side effects or complications of the PDT procedure. Pharyngoscopy indicated reduction of inflammatory manifestations, and, in particular cases, hypervascularization was observed. Morphological changes were also detected in the course of monitoring, which are in agreement with pharyngoscopy results. Microbiologic study after PDT revealed no pathogenic bacteria; however, in particular cases, saprophytic flora was detected.

Emergency Health Care Professionals' Understanding of the Costs of Care in the Emergency Department.

BACKGROUND: Efficiency and fiscal responsibility are important to the equal, safe, and effective delivery of care in the emergency department, where all presenting patients must be evaluated for emergent conditions. Health care professionals' understanding of the costs of care is a first step to developing rational approaches for the efficient distribution of the finite resources hospitals and emergency departments have at their disposal to reduce costs to patients and health care systems. OBJECTIVE: To determine emergency department health care professionals' knowledge of the costs to patients of routine care delivered in the emergency department. METHODS: An internet-based survey of currently practicing emergency medicine health care professionals with various levels of training (physicians, residents, physician assistants, and nurse practitioners) was conducted to evaluate their ability to identify the cost of care for 3 common presentations to the emergency department: abdominal pain, dyspnea, and sore throat. RESULTS: Four hundred forty-one emergency medicine health care professionals participated. In the 3 cases presented, correct costs were determined by 43.0%, 32.0%, and 40.1% of participants, respectively. Geographic region was not related to cost determination. Larger institution size was related to greater cost chosen (P=.01). Higher level of training was significantly correlated with perceived understanding of cost (P<.001); however, it was not related to accurate cost assessment in this study. CONCLUSION: Emergency medicine health care professionals have an inadequate understanding of the costs associated with care routinely provided in the emergency department.

It's not what you do it's the way that it's measured: quality assessment of minor ailment management in community pharmacies.

BACKGROUND: Effective management of minor ailments in community pharmacies could reduce the burden on alternative high-cost services (general practices, Emergency Departments). Evidence is needed regarding the appropriateness of management of these conditions in community pharmacies. OBJECTIVE: To explore the appropriateness of minor ailment management in community pharmacies. SETTING: Prospective, observational study of simulated patient (SP) visits to community pharmacies in Grampian (Scotland) and East Anglia (England). METHOD: Eighteen pharmacies (nine per centre) were recruited within a 25-mile radius of Aberdeen or Norwich. Consultations for four minor ailments were evaluated: back pain; vomiting/diarrhoea; sore throat; and eye discomfort. Each pharmacy received one SP visit per ailment (four visits/pharmacy; 72 visits total). Visits were audio-recorded and SPs completed a data collection form immediately after each visit. PRIMARY OUTCOME MEASURE: Each SP consultation was assessed for appropriateness against product licence, practice guidelines and study-specific consensus standards developed by a multi-disciplinary consensus panel. RESULTS: Evaluable data were available for 68/72 (94.4%) visits. Most (96%) visits resulted in the sale of a product; advice alone was the outcome of three visits. All product sales complied with the product licence, 52 (76%) visits complied with practice guidelines and seven visits achieved a 'basic' standard according to the consensus standard. CONCLUSION: Appropriateness of care varied according to the standard used. Pharmacy-specific quality standards are needed which are realistic and relevant to the pharmacy context and which reflect legal and clinical guidelines to promote the safe and effective management of minor ailments in this setting.

Cost-effectiveness of pharmacist-provided treatment of adult pharyngitis.

BACKGROUND: There are over 12 million ambulatory care visits for acute pharyngitis annually in the United States. Current guidelines recommend diagnosis through culture or rapid antigen detection test (RADT) and relatively straightforward treatment. Community pharmacists may provide cost-effective care for disease states such as group A streptococcus (GAS) pharyngitis. OBJECTIVES: The objective of this research is to evaluate the cost-effectiveness of a community pharmacist-as-provider program for the diagnosis and treatment of pharyngitis caused by GAS as compared with standard of care. METHODS: A cost-effectiveness analysis was conducted to compare treatment for adult pharyngitis patients. In addition to 5 physician-provided treatment strategies, the episodic costs and benefits of treatment provided by pharmacists using RADT and walk-in clinics using RADT were also considered. Model parameters were derived through a comprehensive review of literature and from the Centers for Medicare and Medicaid Services physician fee schedule. Utilities were expressed in quality-adjusted life-days (QALDs) to account for the relatively short duration of most cases of pharyngitis. RESULTS: Using a cost-effectiveness threshold of $137 per QALD, GAS treatment provided by a pharmacist was the most cost-effective treatment. Pharmacist treatment dominated all of the other methods except physician culture and physician RADT with follow-up culture. The incremental cost-effectiveness ratio (ICER) for physician culture was $6042 per QALD gained and $40,745 for physician RADT with follow-up culture. CONCLUSIONS: This model suggests that pharmacists may be able to provide a cost-effective alternative for the treatment of pharyngitis caused by GAS in adult patients.

Diagnosis and management of acute pharyngitis in a paediatric population: a cost-effectiveness analysis.

Acute pharyngitis is one of the most frequent causes of primary care physician visits; however, there is no agreement about which is the best strategy to diagnose and manage acute pharyngitis in children. The aim of the current study was to evaluate the cost-effectiveness of the recommended strategies to diagnose and manage acute pharyngitis in a paediatric population. A decision tree analysis was performed to compare the following six strategies: "treat all", "clinical scoring", "rapid test", "culture", "rapid test + culture" and "clinical scoring + rapid test". The cost data came from the Spanish National Health Service sources. Cost-effectiveness was calculated from the payer's perspective. Effectiveness was measured as the proportion of patients cured without complications from the disease and did not have any reaction to penicillin therapy; a sensitivity analysis was performed. The findings revealed that the "clinical scoring + rapid test" strategy is the most cost-effective, with a cost-effectiveness ratio of 50.72 . This strategy dominated all others except "culture", which was the most effective but also the most costly. The sensitivity analysis showed that "rapid test" became the most cost-effective strategy when the clinical scoring sensitivity was <91% and its specificity was ≤9%. In conclusion, the use of a clinical scoring system to triage the diagnoses and performing a rapid antigen test for those with a high score is the most cost-effective strategy for the diagnosis and management of acute pharyngitis in children. When the clinical scoring system has a low diagnostic accuracy, testing all patients with rapid test becomes the most cost-effective strategy.

Evaluating the supportive care costs of severe radiochemotherapy-induced mucositis and pharyngitis : results from a Northwestern University Costs of Cancer Program pilot study with head and neck and nonsmall cell lung cancer patients who received care at a county hospital, a Veterans Administration hospital, or a comprehensive cancer care center.

BACKGROUND: Few studies have examined the costs of supportive care for radiochemotherapy-induced mucosits/pharyngitis among patients with head and neck cancer (HNC) or lung cancers despite the documented negative clinical impact of these complications. METHODS: The authors identified a retrospective cohort of patients with HNC or nonsmall lung cancer (NSCLC) who had received radiochemotherapy at 1 of 3 Chicago hospitals (a Veterans Administration hospital, a county hospital, or a tertiary care hospital). Charts were reviewed for the presence/absence of severe mucositis/pharyngitis and the medical resources that were used. Resource estimates were converted into cost units obtained from standard sources (hospital bills, Medicare physician fee schedule, Red Book). Estimates of resources used and direct medical costs were compared for patients who did and patients who did not develop severe mucositis/pharyngitis. RESULTS: Severe mucositis/pharyngitis occurred in 70.1% of 99 patients with HNC and in 37.5% of 40 patients with NSCLC during radiochemotherapy. The total median medical costs per patient were USD 39,313 for patients with mucositis/pharyngitis and USD 20,798 for patients without mucositis/pharyngitis (P = .007). Extended inpatient hospitalization accounted for USD 12,600 of the increased medical costs (median 14 days [USD 19,600] with severe mucositis/pharyngitis vs 5 days [USD 7,000] without; P = .017). For patients who had HNC with mucositis/pharyngitis, incremental inpatient hospitalization costs were USD 14,000, and total medical costs were USD 17,244. For patients who had NSCLC with mucositis/pharyngitis, these costs were USD 11,200 and USD 25,000, respectively. CONCLUSIONS: In the current study, the medical costs among the patients with HNC and NSCLC who received radiochemotherapy were greater for those who developed severe mucositis/pharyngitis than for those who did not.

Phage therapy of staphylococcal infections (including MRSA) may be less expensive than antibiotic treatment.

The current drama of antibiotic resistance has revived interest in phage therapy. In response to this challenge, a phage therapy center was established at our Institute in 2005 which accepts patients from Poland and abroad with antibiotic-resistant infections. We now present data showing that efficient phage therapy of staphylococcal infections is no longer a treatment of last resort (when all antibiotics fail), but allows for significant savings in the costs of healthcare.

Evaluation of the American Academy of Pediatrics Principles on Management of Common Office Infections in a managed care setting.

The American Academy of Pediatrics has outlined principles for management of common office infections. We evaluated the impact of these principles at St. John's Health System. Study design was a pre and post guideline analysis of claims data and a randomized chart review. There was a high baseline compliance present with the AAP recommendations. There was a 33.5% increase in the use of throat cultures or streptococcal agglutination screens for diagnosis of upper respiratory infections (p = .001) and an 86% decrease in the use of sinus films (p < .001). We conclude that the AAP principles resulted in a significant change in clinical practice.

Health insurance status and ambulatory care for children.

BACKGROUND: Many children in the United States lack health insurance. We tested the hypothesis that these children are less likely than children with insurance to visit a physician when they have specific conditions for which care is considered to be indicated. METHODS: We examined the association between whether children were covered by health insurance and whether they received medical attention from a physician for pharyngitis, acute earache, recurrent ear infections, or asthma. Data were obtained on the subsample of 7578 children and adolescents 1 through 17 years of age who were included in the 1987 National Medical Expenditures Survey, a national probability sample of the civilian, noninstitutionalized population. RESULTS: Uninsured children were more likely than children with health insurance to receive no care from a physician for all four conditions (unadjusted odds ratios, 2.38 for pharyngitis; 2.04 for acute earache; 2.84 for recurrent ear infections; and 1.87 for asthma). Multiple logistic-regression analysis was subsequently used to control for age, sex, family size, race or ethnic group, region of the country, place of residence (rural vs. urban), and household income. After adjustment for these factors, uninsured children remained significantly more likely than insured children to go without a visit to a physician for pharyngitis (adjusted odds ratio, 1.72; 95 percent confidence interval, 1.11 to 2.68), acute earache (1.85; 95 percent confidence interval, 1.15 to 2.99), recurrent ear infections (2.12; 95 percent confidence interval, 1.28 to 3.51), and asthma (1.72; 95 percent confidence interval, 1.05 to 2.83). CONCLUSIONS: As compared with children with health insurance, children who lack health insurance are less likely to receive medical care from a physician when it seems reasonably indicated and are therefore at risk for substantial avoidable morbidity.

The comparative cost-effectiveness of statistical decision rules and experienced physicians in pharyngitis management.

We examined whether probability-based decisions for streptococcal pharyngitis, using probabilities derived from predictive models along with Tompkins' decision rules, could be more cost-effective than the actual decisions of ten physicians. We retrospectively calculated the probability of a positive throat culture ("disease") for each of 310 patients using four different models based on discriminant analysis (1), a branching algorithm (2), and logistic regression (3 and 4). "Projected decisions" were based on these probabilities and Tompkins' rules. We calculated direct medical and indirect costs per correct action taken (diseased patient-treated or nondiseased patient-not-treated). Two models' projected decisions were more cost-effective than the physicians'. Model 1 primarily would have reduced treatment costs (leaving no diseased patient untreated); model 4 primarily would have reduced throat culture costs (with 15% projected undertreatment). While using statistical decision rules may be cost-effective in this setting, their adoption should be consistent with physician and patient priorities.

Incidence and management of sore throat in general practice.

A total of 1051 patients with sore throat were registered by 358 general practitioners (GPs) each participating for one week some time during a one-year study period. Contacts related to emergency medical service work, and contacts by telephone only were also included. The annual incidence of sore throat was estimated to be 100 per 1 000 person years. A bacterial or presumedly bacterial etiology was clinically diagnosed in 64% of the patients, and a viral or presumedly viral etiology in 30% of cases, while for six per cent of the patients, the GP was in doubt as to the etiology. The strategy of management was as follows: nine per cent had a throat swab taken and antibiotics prescribed; 15% were swabbed, and did not receive an immediate prescription; 54% were prescribed antibiotics without being swabbed; and 23% were neither swabbed nor treated with antibiotics. With increasing age of the doctor, increasing frequencies were found regarding the clinical assumption of a bacterial etiology and prescribing of antibiotics, whereas the frequency of obtaining throat swabs decreased. Similar findings were made when the type of contact was home visit as opposed to contact at the surgery.

Patients' therapeutic preferences in an ambulatory care setting.

One thousand two hundred-fifteen adult outpatients of an urban health maintenance organization completed questionnaires containing four hypothetical clinical situations. Of these patients, 72 per cent preferred a non-drug "home remedy" when given a choice among that and two different drug options. Risk aversion and willingness to accept current discomfort were stronger than demographic variables in predicting this preference. We conclude that patients informed about the risks and benefits of drug and non-drug therapies will prefer the latter if that option is offered.

Episode-based efficiency comparisons for physicians and nurse practitioners.

Most previous studies comparing the efficiency of new health practitioners with that of physicians have used the visit as the basic unit of output. Several researchers have noted, though, that the episode is a conceptually superior output unit in several respects, although it is more complex to deal with methodologically. This study demonstrates the application of episode-based methods for comparing the efficiency of physicians with that of nurse practitioners. Data are drawn from the information system of the Columbia Medical Plan and from observations of provider time inputs. The analysis is confined to care episodes for otitis media and sore throat in the Department of Pediatrics. Results indicate that per episode costs with nurse practitioners as the initial provider are approximately 20 per cent below the costs of episodes in which physicians are the initial provider. Examination of a limited amount of data on patient-reported measures of effectiveness indicates that while nurse practitioners' care is less costly, it is not less effective. These findings are particularly interesting in light of recent doubts expressed about cost-savings from using new health practitioners, and particularly nurse practitioners, in group practice settings.

Treating sore throats in the emergency room. The importance of follow-up in decision making.

Evaluation and treatment of emergency room patients complaining of sore throats are complicated by an unknown probability of follow-up. Tompkins' analysis of cost-effective sore throat management strategies was modified by adding an expression for variable follow-up rate. The original analysis specified a culture range when the probability of streptococcal infection was between 0.05 and 0.20, while the expanded analysis demonstrates that this range decreases with decreasing follow-up. For follow-up rates of 0.70 or less, all patients would be in either the treatment or no treatment group. This analysis demonstrates the importance of follow-up in out-patient decision making, and illustrates the methodology for including follow-up (and similar factors) in our analyses.

Quality assurance through automated monitoring and concurrent feedback using a computer-based medical information system.

A computer-based medical information system (COSTAR) has been used to support a quality assurance program where the data collection is an integral part of the patient care recording activity and, therefore, does not require a separate abstracting or encoding process. This program utilizes concurrent audit to detect deficiencies in patient care, and automatic rapid feedback to the responsible provider in time to allow the provider to correct the deficiency. This system has been demonstrated to improve follow-up of throat cultures, positive for Group A Beta hemolytic streptococcus. It is well accepted by the medical staff whose practice is being audited. Because the data are collected as part of the routine operation of COSTAR, the computer monitoring and feedback have only a small incremental cost.