Assessing Health Care Utilization and Compliance in Kawasaki Disease.

OBJECTIVE: To characterize health care utilization and costs associated with care after diagnosis of Kawasaki disease including adherence to guidelines for echocardiograms. STUDY DESIGN: We analyzed children hospitalized for Kawasaki disease using 2015-2017 national Truven MarketScan commercial claims data. The mean 90-day prehospitalization utilization and costs were quantified and compared with the 90 days posthospitalization via Wilcoxon 2-sample test. Adherence to echocardiogram guidelines was examined using multivariable logistic regression to identify factors associated with adherence. RESULTS: The mean total payments 90 days prior to hospitalization ($2090; n = 360) were significantly lower than those after discharge ($3778), though out of pocket costs were higher ($400 vs $270) (P < .0001). There was an increase in office visits, medical procedures, and echocardiograms after discharge. A majority of health care utilization before hospitalization occurred in the 7 days immediately prior to the date of admission; 51% obtained an echocardiogram within the first 2 weeks, and 14% were completely adherent with recommendations. Children with greater utilization prior to admission were more likely to adhere to American Heart Association guidelines for follow-up echocardiograms (OR 1.03, 95% CI 1.01-1.06). CONCLUSIONS: Outpatient health care expenditure nearly doubles after Kawasaki disease hospital discharge when compared with prehospitalization, suggesting the financial ramifications of this diagnosis persist beyond costs incurred during hospitalization. A significant portion of patients do not receive guideline recommended follow-up echocardiograms. This issue should be explored in more detail given the morbidity and mortality associated with this diagnosis.

A Cost Comparison of Infliximab Versus Intravenous Immunoglobulin for Refractory Kawasaki Disease Treatment.

BACKGROUND AND OBJECTIVES: In 10% to 20% of cases, Kawasaki disease is refractory to intravenous immunoglobulin (IVIg), an expensive medication under a national shortage. Data suggest that infliximab is a viable alternative to a second dose of IVIg, with similar efficacy and safety. We compared the cost of a second IVIg dose to that of infliximab in the treatment of refractory Kawasaki disease (rKD). METHODS: A decision analysis model was used to compare rKD treatments: a second dose of IVIg at 2 g/kg versus infliximab at 10 mg/kg. Infliximab monitoring times were 24, 36, and 48 hours. Direct hospital costs beginning at rKD diagnosis were estimated by using 2016-2017 Truven MarketScan data. Redbook was used for drug costs. Calculations were applied to 3 hypothetical cohorts of 100 patients aged 2 (12.5 kg), 4 (16 kg), and 8 years (25.5 kg). Indirect costs included parental missed workdays. RESULTS: The total direct cost for children receiving IVIg was $1 677 801, $1 791 652, and $2 100 675 for the 2-, 4-, and 8-year-old cohorts. The direct cost of infliximab with 24 hours of monitoring was $853 042, $899 096, and $1 024 101, respectively. A 20% bidirectional sensitivity analysis revealed stability of our model, with overall cost savings with use of infliximab. With monitoring 48 hours after infliximab treatment, 20% changes in length of stay (LOS) tipped the balance for the 2- and 4-year-old cohorts. Overall, IVIg and infliximab LOS had the most influence on our model. CONCLUSIONS: Infliximab has potential to yield shorter LOS and significant cost savings in the treatment of rKD. Infliximab treatment, followed by 24 hours of monitoring, nearly halved hospital costs, regardless of age.

A Quality Improvement Project to Optimize Fluoride Varnish Use in a Pediatric Outpatient Clinic with Multiple Resident Providers.

The pediatric clinic at Kapi'olani Medical Center provides dental varnish to prevent decay. A chart review (conducted August 1-31, 2017) revealed that only 49.6% of eligible children received varnish. Among those who did not receive varnish, no explanation was provided in 83.9% of the charts. This quality improvement project was designed to increase delivery and documentation of dental varnish. The participants were 14-15 pediatric and psychiatry residents (11 present for all cycles). Cycle 1 interventions were a 5-minute resident educational session on the importance and process of fluoride varnish, and visual reminders on all order entry computers in the clinic. Cycle 2 intervention consisted of a prompt added to the clinic's default well child visit templates requiring notation of whether varnish was given and a reason if not. Data for cycle 2 was collected over 6 weeks as some residents chose to use their own templates, serving as an unplanned comparison group. Application of varnish increased to 77.7% (P < .001) after cycle 1, and was statistically unchanged for cycle 2 (74% (P = .24)). Documentation of reason for lack of varnish was missing in 80% (P = .59) after cycle 1 and 17 % (P < .001) after cycle 2 (with prompt). In the cycle 2 comparison group using their own templates, the varnish application rate was 71% (P < .001) with no explanation for lack of varnish 84% of the time (P = .95). Brief educational interventions may result in increased use of fluoride varnish in resident-based clinics. Task based prompts or stop measures in electronic medical record templates can improve documentation, which can inform efforts to improve varnish application.

Disseminated Cat Scratch Disease in Pediatric Patients in Hawai'i.

Cat scratch disease is known to be a generally benign, self-resolving illness associated with non-specific symptoms, including lymphadenopathy, fever, fatigue, anorexia, and headaches. However, it can also cause disseminated disease with a wide range of manifestations, including liver and spleen microabscesses, osteomyelitis, encephalitis, and uveitis. Eighteen pediatric cases of disseminated cat scratch disease at a single center in Hawai'i are described. This case series emphasizes the importance of disease recognition and use of appropriate diagnostic tools and disease management. The disease burden of pediatric patients with disseminated cat scratch disease in the state of Hawai'i has a high incidence and should be considered in pediatric patients with prolonged febrile illnesses.