Standardizing morphine use for ventilated preterm neonates with a nursing-driven comfort protocol.

OBJECTIVE: To test whether implementing a nursing-driven comfort protocol standardizes morphine use in one neonatal intensive care unit (NICU) and to examine how non-standard morphine (N-SM) relates to days of ventilation, days of total parenteral nutrition (TPN) and length of stay (LOS). STUDY DESIGN: This was a retrospective/prospective observational study using pharmacy records, medical records, and an outcomes database. Comfort protocol implementation began February 2011 and was applied to preterm, ventilated neonates <1500 grams. Pre- and post-implementation proportions of N-SM days were compared using the binomial test. A percent 'P'-chart spanning 30 quarters was constructed with statistical-process control analysis. Multivariable linear regression adjusting for acuity assessed the relationship between N-SM use and days of ventilation, TPN and LOS. RESULT: Hundred and thirty-four patients met inclusion criteria, 116 prior to and 18 after implementation. The proportion of patients given N-SM for one or more days decreased from 59 to 35% after protocol implementation (P = 0.017). A 9-month period of decreased N-SM days was observed after protocol implementation. Controlling for acuity, each additional day of N-SM use was associated with 0.47 more days of ventilation (95% confidence interval (CI): 0.26-0.69, P < 0.001) and 0.52 more days of TPN (95% CI: 0.35-0.68, P < 0.001). Exposure to N-SM was associated with 17 additional days of hospitalization (P = 0.009, 95% CI: 4.5-30). CONCLUSION: Implementing a nursing-driven comfort protocol significantly reduced N-SM use. N-SM in the NICU is negatively associated with key clinical outcomes. Testing similar protocols in other settings is warranted.

Evaluating patterns of morphine use in a neonatal intensive care unit after NEOPAIN.

OBJECTIVE: To test the hypothesis that use of morphine for sedation of ventilated premature neonates has not changed despite evidence-based recommendations. STUDY DESIGN: Retrospective chart review. RESULTS: Of 410 ventilated patients, 129 received a morphine infusion. The annual percentage of ventilated patients started on an infusion did not vary significantly from 2005-2010 (range: 27%-37%, mean: 32%, χ2 test for trend p = 0.60). Patients given morphine infusion had a lower median estimated gestational age at birth (26 0/7 weeks versus 27 6/7 weeks), and a lower median birth weight (762 versus 1010 grams). CONCLUSION: Use of morphine as a sedative and/or pre-emptive analgesic agent for critically ill, ventilated, premature neonates has not decreased at the study site despite evidence-based recommendations against this treatment approach. This is an area of care that may benefit from quality improvement interventions.

Parent expectations for antibiotics, physician-parent communication, and satisfaction.

OBJECTIVES: To explore how parents communicate their preferences for antibiotics to their child's physician and to examine whether physicians can communicate why antibiotics are not being prescribed in a way that maintains satisfaction with the visit. DESIGN: Previsit survey of parents, audiotaping of the study encounters, and a postvisit survey of parents and physicians. SETTING: Two private pediatric practices. PARTICIPANTS: Ten physicians (response rate = 77%) and a consecutive sample of 295 eligible parents (response rate = 86%) who attended acute care visits for their children between October 1996 and March 1997. MAIN OUTCOME MEASURES: Physician-perceived pressure to prescribe antibiotics and parental visit-specific satisfaction. RESULTS: Fifty percent of parents expressed a previsit expectation for antibiotics. Among these parents, only 1% made a direct verbal request for them. Even when no direct requests for antibiotics were made, physicians still perceived an expectation for antibiotics 34% of the time. Among parents who did not receive expected antibiotics, those offered a contingency plan from the physician (i.e., the possibility of receiving antibiotics in the future if their child did not get better) had a higher mean satisfaction score than parents not receiving a contingency plan (76 vs. 58.9; P<.05). CONCLUSION: Physicians should consider providing a contingency plan to parents who expect antibiotics for their children when there is no clinical indication. Further study is needed to determine how parents indirectly communicate their desire for antibiotics and what additional communication techniques physicians can use to resist the overprescribing of antibiotics.

How much explanation is enough? A study of parent requests for information and physician responses.

OBJECTIVE: To examine the relationship between doctor-parent communication patterns and parents' perceptions that they were listened to by the doctor. DESIGN: Cross-sectional, clinic-based survey. Before the visit, parents were asked about the strength of their desires/preferences for being listened to; after the visit, they were asked if their desires were fulfilled and to rate their satisfaction with care. Encounters were audiotaped, transcribed, and coded for parent requests for information and action and physician responses to those requests. Coding was performed using an adapted version of the Taxonomy of Requests by Patients (TORP). Physician responses to parental requests for information were coded as brief, moderate, or prolonged fulfillment or as partially fulfilled, ignored, or denied. SETTING: Two private pediatric practices, 1 community based and 1 university based. PARTICIPANTS: Ten of 13 eligible physicians (participation rate, 77%) and 306 of 356 eligible parents (participation rate, 86%) who sought care for their children's respiratory illnesses. Parents were invited to participate if they spoke and read English and if their child was 2-10 years old, had a chief complaint of cold symptoms, and was seeing one of the participating physicians. Complete data were obtained for 287 doctor-parent encounters (94%). RESULTS: Before the visit, 74% of parents reported that they considered it necessary for the physician to listen to their ideas about their child's illness. Among these parents, 62% (n = 130) reported after the visit that the physician had listened to their ideas. As the proportion of moderate-length responses to parent requests for information increased, parents were significantly more likely to report being listened to (P <.05). Multivariate results indicated a 59% probability of parents reporting that they were listened to when given moderate-length responses, 45% when given brief responses, 39% when given prolonged responses, and 12% when requests for information were only partially fulfilled, ignored, or denied. The length of response to parent requests for information was not related to overall parent satisfaction. CONCLUSIONS: Parents who received moderate-length answers to their questions were most likely to report that they were listened to. Although it is assumed that lengthier, in-depth explanations result in higher satisfaction, this study suggests that more doctor talk does not necessarily constitute better communication.

Screening for chlamydia in adolescents and young women.

OBJECTIVE: To measure the proportion of sexually active females aged 15 to 25 years who received a screening test for Chlamydia trachomatis infection during the previous year. DESIGN: Administrative data were used to identify females in the target age range who were likely to be sexually active. Medical record data were reviewed for a sample to determine whether the administrative algorithm was acceptable. Laboratory claims data and medical record data were used to identify females who had had a screening test for chlamydia. SETTING: Four geographically dispersed US managed health care plans. PATIENTS: We studied 19,214 sexually active females aged 15 to 25 years continuously enrolled for calendar year 1997 in 1 of 4 major US health plans who had a visit to their health care provider during that year. Sexual activity was determined using an algorithm designed for use with administrative data. MAIN OUTCOME MEASURE: Rates of chlamydia screening among sexually active females aged 15 to 25 years. RESULTS: The proportion of females aged 15 to 25 years identified as sexually active by the administrative data algorithm in the 4 health plans was similar (43%-54%; P =.79). However, substantial variation was found in rates of chlamydia screening for eligible females in these 4 health plans (2%-42%; P<. 001). Plans varied considerably in the types of visits (eg, sexually transmitted disease screening or pregnancy) that determined eligibility for the measure. CONCLUSIONS: A measure of health plan performance on screening for chlamydia in young females using administrative data is feasible and provides useful results despite some flaws in estimation. There is room for improvement in rates of chlamydia screening in sexually active females aged 15 to 25 years.

Health and cost-benefits of chlamydia screening in young women.

BACKGROUND: The Health Plan Employer Data and Information Set (HEDIS) is a set of performance measures used to assess the quality of care delivered in managed care plans. New measures that address unevaluated areas of care are continuously being developed. Chlamydia screening among young women is one new measure that was recently adopted by the National Committee for Quality Assurance (NCQA) for inclusion in HEDIS. An essential criterion for new measures is that the clinical intervention is beneficial to health and cost-effective. GOAL: To assess the health benefits and cost-effectiveness of chlamydia screening among young women. STUDY DESIGN: A focused review of the literature was performed using Medline. Articles addressing the epidemiology of chlamydia infection, its health consequences, and the benefits, problems, and cost-effectiveness associated with chlamydia screening are reviewed. RESULTS: The literature reviewed shows scientific and cost-effectiveness data that support the adoption of the HEDIS measure for chlamydia screening among young women. CONCLUSION: The National Committee for Quality Assurance's recent adoption of the measure for chlamydia screening among young women into the formal HEDIS measurement set is justifiable from a health benefit standpoint and from a cost-effectiveness standpoint.

The relationship between perceived parental expectations and pediatrician antimicrobial prescribing behavior.

CONTEXT: Despite growing concern over the escalating antimicrobial resistance problem, physicians continue to inappropriately prescribe. It has been suggested that a major determinant of pediatrician antimicrobial prescribing behavior is the parental expectation that a prescription will be provided. OBJECTIVES: To explore the extent to which parental previsit expectations and physician perceptions of those expectations are associated with inappropriate antimicrobial prescribing; and to explore the relationship between fulfillment of expectations and parental visit-specific satisfaction. DESIGN: Previsit and postvisit survey of parents and postvisit survey of physicians. SETTING: Two private pediatric practices, one community based and one university based. PARTICIPANTS: Ten physicians (response rate = 77%), and a consecutive sample of 306 eligible parents (response rate = 86%) who were attending sick visits for their children between October 1996 and March 1997. Parents were screened for eligibility in the waiting rooms of the two practices and were invited to participate if they spoke and read English and their child was 2 to 10 years old, had a presenting complaint of ear pain, throat pain, cough, or congestion, was off antimicrobial therapy for the past 2 weeks, and was seeing one of the participating physicians. MAIN OUTCOME MEASURES: Antimicrobial prescribing decision, probability of assigning a bacterial diagnosis, and parental visit-specific satisfaction. RESULTS: Based on multivariate analysis, physicians' perceptions of parental expectations for antimicrobials was the only significant predictor of prescribing antimicrobials for conditions of presumed viral etiology; when physicians thought a parent wanted an antimicrobial, they prescribed them 62% of the time versus 7% of the time when they did not think the parent wanted antimicrobials. However, physician antimicrobial prescribing behavior was not associated with actual parental expectations for receiving antimicrobials. In addition, when physicians thought the parent wanted an antimicrobial, they were also significantly more likely to give a bacterial diagnosis (70% of the time versus 31% of the time). Failure to meet parental expectations regarding communication events during the visit was the only significant predictor of parental satisfaction. Failure to provide expected antimicrobials did not affect satisfaction. CONCLUSIONS: The antibiotic resistance epidemic should lead to immediate replication of this study in a larger more generalizable population. If inaccurate physician perceptions of parent desires for antimicrobials for viral infections are confirmed, then an intervention to change the way physicians acquire this set of perceptions should be undertaken.

Assessing the quality of healthcare provided to children.

OBJECTIVE: To present a conceptual framework for evaluating quality of care for children and adolescents, summarize the key issues related to developing measures to assess pediatric quality of care, examine some existing measures, and present evidence about their current level of performance. PRINCIPAL FINDINGS: Assessing the quality of care for children poses many challenges not encountered when making these measurements in the adult population. Children and adolescents (from this point forward referred to collectively as children unless differentiation is necessary) differ from adults in two clinically important ways (Jameson and Wehr 1993): (1) their normal developmental trajectory is characterized by change, and (2) they have differential morbidity. These factors contribute to the limitations encountered when developing measures to assess the quality of care for children. The movement of a child through the various stages of development makes it difficult to establish what constitutes a "normal" outcome and by extension what constitutes a poor outcome. Additionally, salient developmental outcomes that result from poor quality of care may not be observed for several years. This implies that poor outcomes may be observed when the child is receiving care from a delivery system other than the one that provided the low-quality care. Attributing the suboptimal outcome to the new delivery system would be inappropriate. Differential morbidity refers to the fact that the type, prevalence, and severity of illness experienced by children is measurably different from that observed in adults. Most children experience numerous self-limited illness of mild severity. A minority of children suffer from markedly more severe diseases. Thus, condition-specific measures in children are problematic to implement for routine assessments because of the extremely low incidence and prevalence of most severe pediatric diseases (Halfon 1996). However, children with these conditions are potentially the segment of the pediatric population that can be most affected by variations in the quality of care. Improving the care provided to these children is likely to have the largest impact on quality of life and longevity. The low prevalence of most severe pediatric diseases also makes it difficult to evaluate the effectiveness of new treatment modalities; multi-center trials or long enrollment periods are usually required to obtain a large enough patient sample to conduct the necessary randomized controlled trials or cohort studies. Another challenge encountered when measuring quality of care for children is that, in most cases, they depend on adults to both obtain care and to report on the outcomes of that care. Parents and their children may have different perceptions of what defines health or have different levels of satisfaction with the care they receive. Children, particularly those with special needs, also depend on a broad range of services including the medical system, community intervention programs, social programs, and school-based services. Dependency on these various services adds to the difficulty of measuring and appropriately attributing health outcomes observed in children to a particular service delivery entity. Adolescents also depend on adults for access to some of their care; however, they have special needs related to confidentiality and parent-child information sharing. Adolescents commonly seek care at facilities, such as school-based clinics, that allow them to obtain confidential care. These facilities usually provide out-of-health plan care for these children, which raises special issues related to information availability for quality assessments and for assessing utilization patterns in this population. If the source of poor health outcomes is not known, quality improvement is not possible. The many challenges faced when constructing pediatric (this term will be used to refer to both children and adolescents) quality of care measures have resulted in few of these instruments being developed specifically for children. Most of the measures developed to date have either a very limited pediatric component or still require the process or outcome validation step. Although several practice guidelines and indicators of quality have been constructed, a conceptual framework to guide the development of such tools for quality assessment in the pediatric population is lacking. CONCLUSIONS: Pediatric health services researchers and the organizations that fund this work need to focus on developing a set of quality assessment tools that will address several challenging issues. Working within the context of the conceptual framework presented, we draw several conclusions related to issues that should be considered in developing quality of care measures for children.

Local regeneration in the retina of the goldfish.

We have studied regeneration of the retina in the goldfish as a model of regenerative neurogenesis in the central nervous system. Using a transscleral surgical approach, we excised small patches of retina that were replaced over several weeks by regeneration. Lesioned retinas from three groups of animals were studied to characterize, respectively, the qualitative changes of the retina and surrounding tissues during regeneration, the concomitant cellular proliferation, and the quantitative relationship between regenerated and intact retina. The qualitative and quantitative analyses were done on retinas prepared using standard methods for light microscopy. The planimetric density of regenerated and intact retinal neurons was computed in a group of animals in which the normal planimetric density ranged from high to low. Cell proliferation was investigated by making intraocular injections of 5-bromo-2'-deoxyuridine (BUdr) at various survival times to label proliferating cells and processing retinal sections for BUdr immunocytochemistry. The qualitative analysis showed that the surgery created a gap in the existing retina that was replaced with new retina over the subsequent weeks. The BUdr-labeling experiments demonstrated that the excised retina was replaced by regeneration of new neurons. Neuroepithial-like cells clustered on the wound margin and migrated centripetally, appositionally adding new retina to the old. The quantitative analysis showed that the planimetric density of the regenerated neurons approximated that of the intact ones.