Diagnostic reference ranges for pediatric abdominal CT.

PURPOSE: To develop diagnostic reference ranges (DRRs) and a method for an individual practice to calculate site-specific reference doses for computed tomographic (CT) scans of the abdomen or abdomen and pelvis in children on the basis of body width (BW). MATERIALS AND METHODS: This HIPAA-compliant multicenter retrospective study was approved by institutional review boards of participating institutions; informed consent was waived. In 939 pediatric patients, CT doses were reviewed in 499 (53%) male and 440 (47%) female patients (mean age, 10 years). Doses were from 954 scans obtained from September 1 to December 1, 2009, through Quality Improvement Registry for CT Scans in Children within the National Radiology Data Registry, American College of Radiology. Size-specific dose estimate (SSDE), a dose estimate based on BW, CT dose index, dose-length product, and effective dose were analyzed. BW measurement was obtained with electronic calipers from the axial image at the splenic vein level after completion of the CT scan. An adult-sized patient was defined as a patient with BW of 34 cm. An appropriate dose range for each DRR was developed by reviewing image quality on a subset of CT scans through comparison with a five-point visual reference scale with increments of added simulated quantum mottle and by determining DRR to establish lower and upper bounds for each range. RESULTS: For 954 scans, DRRs (SSDEs) were 5.8-12.0, 7.3-12.2, 7.6-13.4, 9.8-16.4, and 13.1-19.0 mGy for BWs less than 15, 15-19, 20-24, 25-29, and 30 cm or greater, respectively. The fractions of adult doses, adult SSDEs, used within the consortium for patients with BWs of 10, 14, 18, 22, 26, and 30 cm were 0.4, 0.5, 0.6, 0.7, 0.8, and 0.9, respectively. CONCLUSION: The concept of DRRs addresses the balance between the patient's risk (radiation dose) and benefit (diagnostic image quality). Calculation of reference doses as a function of BW for an individual practice provides a tool to help develop site-specific CT protocols that help manage pediatric patient radiation doses.

Pay for performance alone cannot drive quality.

OBJECTIVE: To determine whether aligning design characteristics of a pay-for-performance program with objectives of an asthma improvement collaborative builds improvement capability and accelerates improvement. DESIGN: Interrupted time series analysis of the impact of pay for performance on results of an asthma improvement collaborative. SETTING: Forty-four pediatric practices within greater Cincinnati. PARTICIPANTS: Forty-four pediatric practices with 13 380 children with asthma. INTERVENTIONS: The pay-for-performance program rewarded practices for participating in the collaborative, achieving network- and practice-level performance thresholds, and building improvement capability. Pay for performance was coupled with additional improvement interventions related to the collaborative. OUTCOME MEASURES: Flu shot percentage, controller medication percentage for children with persistent asthma, and written self-management plan percentage. RESULTS: The pay-for-performance program provided each practice with the potential to earn a 7% fee schedule increase. Three practices earned a 2% increase, 13 earned a 4% increase, 2 earned a 5% increase, 14 earned a 6% increase, and 11 earned a 7% increase. Between October 1, 2003, and November 30, 2006, the percentage of the network asthma population receiving "perfect care" increased from 4% to 88%. The percentage of the network asthma population receiving the influenza vaccine increased from 22% to 41%, and then to 62% during the prior 3 flu seasons. CONCLUSION: Linking design characteristics of a pay-for-performance program to a collaborative focused on improving care for a defined population, building improvement capability, and driving system changes at the provider level resulted in substantive and sustainable improvement.

Cincinnati Children's Hospital Medical Center: transforming care for children and families.

BACKGROUND: Cincinnati Children's Hospital Medical Center pursues its vision to be the leader in improving child health through the creation of new knowledge, education of professionals and the community, and transformation of our health care delivery system. OVERALL APPROACH TO QUALITY AND SAFETY: The strategic plan focuses on achieving the best medical and quality of life outcomes, patient and family experience of care, and value through horizontal integration of research and delivery system design, thereby accelerating the transfer of new knowledge to the bedside. CREATING QUALITY FROM THE FAMILY PERSPECTIVE: Family members and patients participate at all levels of the organization, from the organizationwide family advisory council, to unit-based inpatient teams, to serving as family faculty who teach pediatric residents and orient new employees. Family members ensure that children's and parents' voices are heard. DISCUSSION: Key factors contributing to ongoing transformation include senior leaders' drive for change, focus on perfection or near-perfection goals, vertical alignment in measures, accountability, improvement capability, commitment to internal and external transparency, and focus on measurement and constancy of purpose.

Exemplar pediatric collaborative improvement networks: achieving results.

A number of pediatric collaborative improvement networks have demonstrated improved care and outcomes for children. Regionally, Cincinnati Children's Hospital Medical Center Physician Hospital Organization has sustained key asthma processes, substantially increased the percentage of their asthma population receiving "perfect care," and implemented an innovative pay-for-performance program with a large commercial payor based on asthma performance measures. The California Perinatal Quality Care Collaborative uses its outcomes database to improve care for infants in California NICUs. It has achieved reductions in central line-associated blood stream infections (CLABSI), increased breast-milk feeding rates at hospital discharge, and is now working to improve delivery room management. Solutions for Patient Safety (SPS) has achieved significant improvements in adverse drug events and surgical site infections across all 8 Ohio children's hospitals, with 7700 fewer children harmed and >$11.8 million in avoided costs. SPS is now expanding nationally, aiming to eliminate all events of serious harm at children's hospitals. National collaborative networks include ImproveCareNow, which aims to improve care and outcomes for children with inflammatory bowel disease. Reliable adherence to Model Care Guidelines has produced improved remission rates without using new medications and a significant increase in the proportion of Crohn disease patients not taking prednisone. Data-driven collaboratives of the Children's Hospital Association Quality Transformation Network initially focused on CLABSI in PICUs. By September 2011, they had prevented an estimated 2964 CLABSI, saving 355 lives and $103,722,423. Subsequent improvement efforts include CLABSI reductions in additional settings and populations.

Transforming safety and effectiveness in pediatric hospital care locally and nationally.

Achieving dramatic, sustainable improvements in the safety and effectiveness of care for children requires a transformational approach to how hospitals individually focus on improvement and learn from each other to achieve national goals. The authors describe a theoretic framework for transformation that includes setting system-level priorities, aligning measures with each priority, identifying breakthrough targets, testing interventions to get results, and spreading successful interventions throughout the organization. Essential key drivers of transformation include leadership, building will, transparency, a business case for quality, patient and family engagement, improvement infrastructure, improvement capability, and reliability and standardization. Improving national system-level measures requires each hospital to pursue its own transformation journey while collaborating with hospitals and other organizations.

Improving influenza immunisation for high-risk children and adolescents.

OBJECTIVE: To improve influenza vaccination rates for high-risk children and adolescents. METHODS: During the 2004-5 influenza season, 5 regional cystic fibrosis (CF) centres, 6 hospital clinics that participated in a similar initiative the previous year, 4 new hospital clinics, and 39 community-based paediatric practices implemented a multicomponent change package consisting of nine improvement strategies designed to increase immunisation of high-risk patients. Each site was encouraged to adopt and customize the improvement strategies to meet their specific culture and needs. The main outcome measure was the proportion of the target population immunised. Surveys sent to the community practices were summarised. RESULTS: The intervention targeted a total of 18 866 high-risk children and 9374 (49.7%) received the influenza vaccination. Community-based practices that actively participated in the collaborative reported using significantly more intervention strategies (mean (SD) 7.4 (2.3) vs 4.6 (1.5), respectively, p = 0.001) and achieved higher immunisation rates (59.3% (13.6%) vs 43.7% (20.5%), respectively, p = 0.01) than non-participating practices. The most frequently implemented change concepts were posters in the office, walk-in clinics or same-day appointments and reminder phone calls. The interventions deemed most helpful were weekend or evening "flu shot only" sessions, walk-in or same-day appointments, reminder calls and special mailings to families. CONCLUSIONS: Implementation of the change package, based on evidence and diffusion of innovation theory, resulted in higher immunisation rates than typically reported in the medical literature, especially for the community-based primary care practices.