Association between ordering patterns and shift-based care in general pediatrics inpatients.

Duty-hour restrictions have forced changes in care models for inpatient services, including an increase in shift work. In this study we aimed to determine whether a shift model compliant with 2011 Accreditation Council for Graduate Medical Education duty-hour standards was associated with more active patient care management. Residents caring for pediatric patients changed from a schedule with extended duty shifts and cross-coverage to one based on day/night shifts, limiting interns to 16 consecutive duty hours. We conducted a retrospective review of orders written under each model. After the intervention, there was a significant increase in the mean number of orders written within the first 12 hours (pre: 0.58 orders vs post: 1.12, P = 0.009) and 24 hours (pre: 1.52 vs post: 2.38, P = 0.004) following admission (not including admission orders), but we did not detect a significantly higher percentage of orders written at night. This shift-based coverage system was associated with a greater number of orders written early in the hospitalization, indicating more active management of clinical problems.

High Rate of Hospital Admissions Among Patients with Cirrhosis Seeking Care in US Emergency Departments.

BACKGROUND AND AIMS: Emergency Departments (ED) can serve as a gateway to specialty care for patients with cirrhosis with limited care access. We described the rates and characteristics of patients with cirrhosis who access United States (US) EDs, and identified factors associated with subsequent hospitalization. METHODS: Using data from the National Hospital Ambulatory Medical Care Survey, cirrhosis-related ED from 2000 to 2009 were identified and compared to all other ED visits. RESULTS: From 2000 to 2009, there were an estimated 1,029,693 cirrhosis and 877 million non-cirrhosis visits. Compared to the general ED population, those with cirrhosis were more frequently male (58 vs. 44 %, p = 0.02), Hispanic (18.6 vs. 10.6 %, p < 0.05), seeking care in urban areas (91.6 vs. 73.4 %, p < 0.05) and had Medicaid/no insurance (43 vs. 35 %, p < 0.01). Patients with cirrhosis were more frequently triaged immediately or emergently (72.3 vs. 54.2 %, p < 0.01). The majority were admitted or transferred to another hospital (66.8 vs. 17.4 %, p < 0.01). Among patients with cirrhosis, patients with age ≥ 65 years were more likely to be admitted (adjusted OR 2.49, 95 % CI 1.08-5.73), and Medicaid/uninsured (adjusted OR 0.34; 95 % CI 0.17-0.67) were less likely to be admitted, after adjusting for patient demographics, hospital characteristics, and triage score. CONCLUSIONS: Patient with cirrhosis account for approximately 100,000 US ED visits annually. The higher admission rates among patients with cirrhosis indicate a high acuity of illness. Older age among those admitted may reflect poorer functional status. Finally, high visit but low admission rates among those with Medicaid/no insurance suggest a gap in specialty care.

Variations in 30-day hospital readmission rates across primary care clinics within a tertiary referral center.

BACKGROUND: Reducing hospital readmissions is a national healthcare priority. Little is known about how readmission rates vary across unique primary care practices. OBJECTIVE: To calculate all-cause 30-day hospital readmission rates at the level of individual primary care practices and identify factors associated with variations in these rates. DESIGN: Retrospective analysis SETTING: Seven primary care clinics affiliated with the University of California, San Francisco (UCSF). PATIENTS: Adults ≥18 years old with a primary care provider (PCP) at UCSF MEASUREMENTS: All-cause 30-day readmission rates were calculated for primary care clinics for discharges between July 1, 2009 and June 30, 2012. We built a model to identify demographic, clinical, and hospital factors associated with variation in rates. RESULTS: There were 12,564 discharges for patients belonging to the 7 clinics, with 8685 index discharges and 1032 readmissions. Readmission rates varied across practices, from 14.9% in Human Immunodeficiency Virus primary care and 7.7% in women's health. In multivariable analyses, factors associated with variation in readmission rates included: male gender (odds ratio [OR]: 1.21, 95% confidence interval [CI]: 1.05-1.40), Medicare insurance (OR: 1.31, 95% CI: 1.05, 1.64; Ref = private), Medicare-Medicaid dual eligible (OR: 1.26, 95% CI: 1.01-1.56), multiple comorbidities, and admitting services. Patients with a departed PCP awaiting transfer assignment to a new PCP had an OR of 1.59 (95% CI: 1.16-2.17) compared with having a current faculty PCP. CONCLUSIONS: Primary care practices are important partners in improving care transitions and reducing hospital readmissions, and this study introduces a new way to view readmission rates. PCP turnover may be an important risk factor for hospital readmissions.

Emergency department visits in the neonatal period in the United States.

OBJECTIVES: This study aimed to estimate the incidence of emergency department (ED) visits in the neonatal period in a nationally representative sample and to examine variation by race. METHODS: The National Hospital Ambulatory Medical Care Survey is a nationally representative survey of utilization of ambulatory care services including EDs. We studied all ED visits for patients who were younger than 28 days old from 2003 to 2008. Using the national birth certificate data, we calculated the visit rates by race. Emergency department visits were also characterized by age, insurance status, diagnosis category, region, and hospital type (safety-net vs non-safety-net hospitals). RESULTS: There was an average of 320,540 neonatal ED visits in the United States per year, with an estimated 7.6% of births visiting the ED within 28 days. Estimated rates of ED visits were highest among non-Hispanic blacks, with 14.4% (95% confidence interval [CI], 10.0-19.2) of newborns having an ED visit in the neonatal period, compared with 6.7% (95% CI, 4.9-7.2) for whites and 7.7% (95% CI, 5.7-9.8) for Hispanics. Hispanic and black neonates were more likely to be seen in safety-net hospitals (75.8%-78.2%) than white (57.1%) patients (P = 0.004). CONCLUSIONS: In this first nationally representative study of neonatal visits to the ED, visits were common, with the highest rates in non-Hispanic blacks. Hispanic and black neonates were more commonly seen in safety-net hospitals. Reasons for high visit rates deserve further study to determine whether hospital discharge practices and/or access to primary care are contributing factors.

Emergency department crowding and younger age are associated with delayed corticosteroid administration to children with acute asthma.

OBJECTIVE: This study aimed to identify factors associated with delayed or omission of indicated steroids for children seen in the emergency department (ED) for moderate-to-severe asthma exacerbation. METHODS: This was a retrospective study of pediatric (age ≤ 21 years) patients treated in a general academic ED from January 2006 to September 2011 with a primary diagnosis of asthma (International Classification of Diseases, Ninth Revision code 493.xx) and moderate-to-severe exacerbations. A moderate-to-severe exacerbation was defined as requiring 2 or more (or continuous) bronchodilators. We determined the proportion of visits in which steroids were inappropriately omitted or delayed (>1 hour from arrival). Multivariable logistic regression models were used to identify patient, physician, and system factors associated with delayed or omitted steroids. RESULTS: Of 1333 pediatric asthma ED visits, 817 were for moderate-to-severe exacerbation; 645 (79%) received steroids. Patients younger than 6 years (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.19-4.24), requiring more bronchodilators (OR, 2.82; 95% CI, 2.10-3.79), initially hypoxic (OR, 2.78; 95% CI, 1.33-5.83), or tachypneic (OR, 1.52; 95% CI, 1.05-2.20) were more likely to receive steroids. Median time to steroid administration was 108 minutes (interquartile range, 65-164 minutes). Steroid administration was delayed in 502 visits (78%). Patients with hypoxia (OR, 1.91; 95% CI, 1.11-3.27) or tachypnea (OR, 1.82; 95% CI, 1.17-2.84) were more likely to receive steroids 1 hour or less of arrival, whereas children younger than 2 years (OR, 0.16; 95% CI, 0.07-0.35) and those arriving during periods of higher ED volume (OR, 0.79; 95% CI, 0.67-0.94) were less likely to receive timely steroids. CONCLUSIONS: In this ED, steroids were underprescribed and frequently delayed for pediatric ED patients with moderate-to-severe asthma exacerbation. Greater ED volume and younger age are associated with delays. Interventions are needed to expedite steroid administration, improving adherence to National Institutes of Health asthma guidelines.

Inpatient care for children, ages 1-20 years, with spina bifida in the United States.

AIMS: To describe the inpatient health service use and insurance types for hospitalized children with spina bifida compared to children generally and to evaluate hospital discharge and insurance type trends over a 10-year study period. METHODS: The cross-sectional secondary data analyses were conducted using the 2000, 2003, 2006 and 2009 Kid's Inpatient Databases. Diagnoses were identified by ICD-9 codes and hospital type was categorized based on the National Association of Children's Hospitals and Related Institutions designations. Chi-squared tests and the Wald test of trend were used for the statistical analyses. RESULTS: Children with spina bifida are more likely to receive their inpatient care in children's hospitals or pediatric units compared to all children. Children with spina bifida were most commonly admitted for shunt malfunction and repair. The percentage of children covered by Medicaid rose during the study period for both children with spina bifida and children generally. CONCLUSIONS: This study is the first of its kind to document longitudinal trends in inpatient utilization, insurance type, and reason for admission for children with spina bifida. The changing trends in insurance coverage should be closely monitored because insurance is closely linked to health care access, which is linked to health outcomes.

Increasing critical care admissions from U.S. emergency departments, 2001-2009.

OBJECTIVES: Little is known about how recent system-wide increases in demand for critical care have affected U.S. emergency departments (EDs). This study describes changes in the amount of critical care provided in U.S. EDs between 2001 and 2009. DESIGN: Analysis of data from the National Hospital Ambulatory Medical Care Survey for the years 2001-2009. SETTING: National multistage probability sample of U.S. ED data. U.S. ED capacity was estimated using the National Emergency Department Inventory-United States. PATIENTS: : ED patients admitted a critical care unit. INTERVENTIONS: None. MEASUREMENTS: Annual hours of ED-based critical care and annual number critical care ED visits. Clinical characteristics, demographics, insurance status, setting, geographic region, and ED length of stay for critically ill ED patients. MAIN RESULTS: Annual critical care unit admissions from U.S. EDs increased by 79% from 1.2 to 2.2 million. The proportion of all ED visits resulting in critical care unit admission increased from 0.9% to 1.6% (ptrend < 0.001). Between 2001 and 2009, the median ED length of stay for critically ill patients increased from 185 to 245 minutes (+ 60 min; ptrend < 0.02). For the aggregated years 2001-2009, ED length of stay for critical care visits was longer among black patients (12.6% longer) and Hispanic patients (14.8% longer) than among white patients, and one third of all critical care ED visits had an ED length of stay greater than 6 hrs. Between 2001 and 2009, total annual hours of critical care at U.S. EDs increased by 217% from 3.2 to 10.1 million (ptrend < 0.001). The average daily amount of critical care provided in U.S. EDs tripled from 1.8 to 5.6 hours per ED per day. CONCLUSIONS: The amount of critical care provided in U.S. EDs has increased substantially over the past decade, driven by increasing numbers of critical care ED visits and lengthening ED length of stay. Increased critical care burden will further stress an already overcapacity U.S. emergency care system.

Association between adaptations to ACGME duty hour requirements, length of stay, and costs.

STUDY OBJECTIVE: To determine whether adaptations to comply with Accreditation Council for Graduate Medical Education (ACGME) duty hour requirements are associated with changes in total cost and length of stay. DESIGN: Retrospective, interrupted time-series cohort study using concurrent control patients. SETTING: UCSF Benioff Children's Hospital, San Francisco, CA. PATIENTS: Inpatients newborn to 18 y on the primary pediatrics medical-surgical unit. Medical patients were studied before and after an intervention, and surgical patients served as a concurrent control group. INTERVENTION: Pediatrics trainees' work schedules were changed from those that relied on prolonged call shifts to those primarily based on shorter day shifts and night shifts. RESULTS: We detected significant relative reductions in length of stay but not in total cost. When the analysis was limited to the subset of patients who did not receive intensive care unit care, length of stay decreased by 18% and total cost decreased by 10%. We did not detect similar changes in the control group. CONCLUSIONS: A trainee staffing model that included shorter shifts as consistent with current ACGME duty hour requirements was associated with reduced length of stay and total costs for patients not in the intensive care unit.

A cluster randomized trial of decision support strategies for reducing antibiotic use in acute bronchitis.

BACKGROUND: National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis. METHODS: We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis. RESULTS: Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites. CONCLUSIONS: Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00981994.

Regional differences in emergency medical services use for patients with acute stroke (findings from the National Hospital Ambulatory Medical Care Survey Emergency Department Data File).

BACKGROUND: Our objectives were to describe the proportion of stroke patients who arrive by ambulance nationwide and to examine regional differences and factors associated with the mode of transport to the emergency department (ED). METHODS: Patients with a primary discharge diagnosis of stroke based on previously validated International Classification of Disease, 9th revision codes were abstracted from the National Hospital Ambulatory Medical Care Survey for the years 2007 to 2009. We excluded subjects<18 years of age and those with missing data. Using logistic regression, we identified independent predictors of arrival by ambulance to the ED. RESULTS: Overall, 566 patients met the entry criteria, representing 2,153,234 patient records nationally, based on 2010 US census data. Of these, 50.4% arrived by ambulance. After adjustment for potential confounders, age was associated with use of an ambulance. In addition, patients residing in the west and south had lower odds of arriving by ambulance for stroke when compared to northeast (South: odds ratio [OR] 0.45 and 95% confidence interval [CI] 0.26-0.76; West: OR 0.45 and 95% CI 0.25-0.84; Midwest: OR 0.56 and 95% CI 0.31-1.01). Compared to the Medicare population, privately insured and self-insured patients had lower odds of arriving by ambulance (OR for private insurance 0.48 and 95% CI 0.28-0.84; OR for self-payers 0.36 and 95% CI 0.14-0.93). Gender, race, urban or rural location of ED, and safety net status was not independently associated with ambulance use. CONCLUSIONS: Patients with stroke arrive by ambulance more frequently in the Northeast than in other regions of the United States. Identifying reasons for this difference may be useful in improving stroke care.

Unintended consequences of a quality measure for acute bronchitis.

OBJECTIVES: To determine whether diagnostic coding shifts might undermine apparent improvements resulting from the 2007 Healthcare Effectiveness Data and Information Set (HEDIS) measure on avoidance of antibiotics for the treatment of adults with acute bronchitis (International Classification of Diseases, Ninth Revision, Clinical Modification code 466.0). STUDY DESIGN: Time series analysis within a primary care network for 3 successive winter seasons from 2006 to 2009. METHODS: All initial adult visits with a primary diagnosis code of 466.0 or 490 (bronchitis, not otherwise specified) were analyzed. Multivariable analysis accounted for clustering of observations by physician. RESULTS: The percentage of visits treated with antibiotics declined significantly for code 466.0 (76.8% to 74.4% to 27.0% of visits over the 3-year study period; P <.0001 for trend) but did not decline for code 490 (86.6% to 87.6% to 82.1% of visits; P = .33 for trend). Use of the 490 code rose significantly over the study period, from 1.5% of total bronchitis visits in year 1 to 84.6% of total bronchitis visits in year 3. As a result, the odds of an antibiotic prescription for codes 466 and 490 combined decreased slightly in year 3 compared with year 1 (odds ratio 0.88; 95% confidence interval 0.78-0.99). CONCLUSIONS: While performance on the specific HEDIS measure improved dramatically during this study period, overall antibiotic prescribing did not decline substantially. Quality measures that assess performance on specific diagnosis codes are imperfect and do not account for shifts in diagnosis coding.

Missing documentation of weight and height at preventive visits for children.

Despite the importance of measuring weight and height at well-child visits, there are limited data on frequency of anthropometric documentation. The authors aimed to identify characteristics associated with missing weight and height documentation at preventive visits for children. Among preventive visits for children from birth to 18 years old, recorded in the National Ambulatory Medical Care and National Hospital Ambulatory Medical Care Surveys for 2005-2009, the authors found that 20.8% had missing weight and/or height (n = 19,033) documentation. Compared with infants younger than 2 years, school-age children (odds ratio [OR] = 1.30; 95% confidence interval [CI] = 1.03-1.64), and adolescents (OR = 1.61; 95% CI = 1.26-2.04) were more likely to lack documentation. Missing documentation was also more likely for visits with nonphysicians (OR = 4.53; 95% CI = 3.17-6.48) and nonpediatricians (OR = 2.63; 95% CI = 2.02-3.41) compared with pediatricians. Efforts to improve weight and height surveillance should be directed to clinics in which midlevel providers and nonpediatric physicians are caring for school-age children and adolescents.

Association of emergency department length of stay with safety-net status.

CONTEXT: Performance measures, particularly pay for performance, may have unintended consequences for safety-net institutions caring for disproportionate shares of Medicaid or uninsured patients. OBJECTIVE: To describe emergency department (ED) compliance with proposed length-of-stay measures for admissions (8 hours or 480 minutes) and discharges, transfers, and observations (4 hours or 240 minutes) by safety-net status. DESIGN, SETTING, AND PARTICIPANTS: The 2008 National Hospital Ambulatory Medical Care Survey (NHAMCS) ED data were stratified by safety-net status (Centers for Disease Control and Prevention definition) and disposition (admission, discharge, observation, transfer). The 2008 NHAMCS is a national probability sample of 396 hospitals (90.2% unweighted response rate) and 34 134 patient records. Visits were excluded for patients younger than 18 years, missing length-of-stay data or dispositions of missing, other, left against medical advice, or dead on arrival. Median and 90th percentile ED lengths of stay were calculated for each disposition and admission/discharge subcategories (critical care, psychiatric, routine) stratified by safety-net status. Multivariable analyses determined associations with length-of-stay measure compliance. MAIN OUTCOME MEASURES: Emergency Department length-of-stay measure compliance by disposition and safety-net status. RESULTS: Of the 72.1% ED visits (N = 24 719) included in the analysis, 42.3% were to safety-net EDs and 57.7% were to non-safety-net EDs. The median length of stay for safety-net was 269 minutes (interquartile range [IQR], 178-397 minutes) for admission vs 281 minutes (IQR, 178-401 minutes) for non-safety-net EDs; 156 minutes (IQR, 95-239 minutes) for discharge vs 148 minutes (IQR, 88-238 minutes); 355 minutes (IQR, 221-675 minutes) for observations vs 298 minutes (IQR, 195-440 minutes); and 235 minutes (IQR, 155-378 minutes) for transfers vs 239 minutes (IQR, 142-368 minutes). Safety-net status was not independently associated with compliance with ED length-of-stay measures; the odds ratio was 0.83 for admissions (95% CI, 0.52-1.34); 1.03 for discharges (95% CI, 0.83-1.27); 1.05 for observations (95% CI, 0.57-1.95), 1.30 for transfers (95% CI, 0.70-2.45]); or subcategories except for psychiatric discharges (1.67, [95% CI, 1.02-2.74]). CONCLUSION: Compliance with proposed ED length-of-stay measures for admissions, discharges, transfers, and observations did not differ significantly between safety-net and non-safety-net hospitals.

Statin use and postoperative atrial fibrillation after major noncardiac surgery.

BACKGROUND: Although statin lipid-lowering medications likely reduce perioperative ischemic complications, few data exist to describe statins' effects on risk for and outcomes of atrial fibrillation following noncardiac surgery. OBJECTIVE: To examine the association between treatment with statin medications and clinically significant postoperative atrial fibrillation (POAF) following major noncardiac surgery. METHODS: A retrospective cohort study of patients aged 18 years or older who underwent major noncardiac surgery between January 1, 2008, and December 31, 2008. Cases of clinically significant POAF were selected by using a combination of International Classification of Diseases-9 codes and clinical variables. We defined statin users as those whose pharmacy data included a charge for a statin drug on the day of surgery, the day after surgery, or both. RESULTS: Of 370,447 patients, 10,957 (3.0%) developed clinically significant POAF; overall, 79,871 (21.6%) received a perioperative statin. Patients receiving statins were generally older (68.8 vs 61.1 years; P <.001) and more likely to be receiving a beta-blocker (50.3% vs 21.6%; P < .001). Statin use was associated with a lower unadjusted rate of POAF (2.6% vs 3.0%; P < .001). After adjustment for patient risk factors and surgery type, odds for POAF remained significantly lower among statin-treated patients (adjusted odds ratio = 0.79; 95% confidence interval = 0.71-0.87; P < .001). Statin use was not associated with differences in cost, length of stay, or mortality among patients who developed POAF. CONCLUSION: Treatment with statin agents appears to be associated with a lower risk for clinically significant POAF following major noncardiac surgery.

Radiological imaging of patients with suspected urinary tract stones: national trends, diagnoses, and predictors.

OBJECTIVES: Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates. METHODS: This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined. RESULTS: Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p < 0.001). In contrast, the use of US remained low, at about 5%, until it decreased beginning in 2005 to 2007 to 2.4% (p = 0.01). The proportion of patients diagnosed with urolithiasis (approximately 18%, p = 0.55), with other significant diagnoses (p > 0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53). CONCLUSIONS: From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

Antibiotic prescribing during pediatric ambulatory care visits for asthma.

OBJECTIVE: National guidelines do not recommend antibiotics as an asthma therapy. We sought to examine the frequency of inappropriate antibiotic prescribing during US ambulatory care pediatric asthma visits as well as the patient, provider, and systemic variables associated with such practice. PATIENTS AND METHODS: Data from the National Ambulatory Medical Care Surveys and National Hospital Ambulatory Medical Care Survey were examined to assess office and emergency-department asthma visits made by children (aged < 18 years) for frequencies of antibiotic prescription. International Classification of Diseases, Ninth Revision (ICD-9) codes were used to assess the presence of coexisting conditions warranting antibiotics. Multivariable logistic regression models assessed associations with the prescription of antibiotics. RESULTS: From 1998 to 2007, an estimated 60.4 million visits occurred for asthma without another ICD-9 code justifying antibiotic prescription. Antibiotics were prescribed during 16% of these visits, most commonly macrolides (48.8%). In multivariate analysis, controlling for patient age, gender, race, insurance type, region, and controller medication use, systemic corticosteroid prescription (odds ratio [OR]: 2.69 [95% confidence interval (CI): 1.68-4.30]) and treatment during the winter (OR: 1.92 [95% CI: 1.05-3.52]) were associated with an increased likelihood of antibiotic prescription, whereas treatment in an emergency department was associated with decreased likelihood (OR: 0.48 [95% CI: 0.26-0.89]). A second multivariate analysis of only office-based visits demonstrated that asthma education during the visits was associated with reduced antibiotic prescriptions (OR: 0.46 [95% CI: 0.24-0.86]). CONCLUSIONS: Antibiotics are prescribed during nearly 1 in 6 US pediatric ambulatory care visits for asthma, ~ 1 million prescriptions annually, when antibiotic need is undocumented. Additional education and interventions are needed to prevent unnecessary antibiotic prescribing for asthma.

Adverse drug events in U.S. adult ambulatory medical care.

OBJECTIVE: To estimate the incidence of adverse drug events (ADEs) associated with health care visits among U.S. adults across all ambulatory settings. DATA SOURCE: We analyzed data from two nationally representative probability sample surveys: the National Ambulatory Medical Care Survey and the National Hospital and Ambulatory Medical Care Survey. From 2005 to 2007, the presence of an ADE was specifically defined, requested, and recorded in these surveys. STUDY DESIGN: Secondary data analysis. PRINCIPAL FINDINGS: An estimated 13.5 million ADE-related visits occurred between 2005 and 2007 (0.5 percent of all visits), the large majority (72 percent) occurring in outpatient practice settings, and the remaining in emergency departments. Older patients (age ≥65 years) had the highest age-specific ADE rate, 3.8 ADEs per 10,000 persons per year. In adjusted analyses of outpatient visits, there was an increased odds of an ADE-related visit with increased medication burden (odds ratio [OR] for six to eight medications compared with no medications, OR 3.83 [2.20, 6.65]), and increased odds of ADEs associated with primary care visits compared with specialty visits (OR 2.22 [1.70, 2.89]). CONCLUSIONS: Approximately 4.5 million ambulatory visits related to ADEs occur each year, the majority of these in outpatient office practices. A greater focus on ADE prevention and detection is warranted among patients receiving multiple medications in primary care practices.

Analgesic prescribing practices can be improved by low-cost point-of-care decision support.

CONTEXT: Codeine has become a controversial choice for analgesia in children compared with other commonly available drugs. OBJECTIVES: To evaluate whether an educational campaign shifted resident prescribing patterns away from codeine toward more appropriate analgesics. METHODS: Our intervention consisted of a pocket-sized reference card given to all trainees and key staff in an inpatient pediatric acute care unit; pediatrics residents also had the option to attend a one-hour lecture. The pocket card recommended against codeine (including rationale) and gave prescription guidance for our institution's preferred formulary alternative analgesics, which include tramadol and hydrocodone. We used inpatient prescribing data to track the prescribing of codeine and alternative medications over time. RESULTS: Following the interventions, there was a significant decrease in the percentage of patients receiving codeine (13.5% of patients received the drug in the year before, 5.4% in the year after, P < 0.0001). Use of hydrocodone-containing analgesics increased overall during the same period (7.4%-16%, P < 0.0001) as did tramadol use (0.2%-2.6%, P < 0.0001). There were no changes in pain management satisfaction scores. CONCLUSION: A simple low-cost educational campaign consisting primarily of a pocket guide to analgesics markedly improved analgesic prescribing patterns, and that improvement extended to services not targeted by the didactic component of our educational campaign. Point-of-care decision support by means of a pocket card may be sufficient for effecting change in medication prescribing patterns of trainees.

Factors associated with prolonged emergency department length of stay for admitted children.

OBJECTIVE: To estimate the prevalence of and to identify factors associated with prolonged emergency department length-of-stay (ED-LOS) for admitted children. METHODS: Data were from the 2001-2006 National Hospital Ambulatory Medical Care Survey. The primary outcome was prolonged ED-LOS (defined as total ED time >8 hours) among admitted children. Predictor variables included patient-level (eg, demographics including race/ethnicity, triage score, diagnosis, and admission to inpatient bed vs intensive care unit), physician-level (intern/resident vs attending physician), and system-level (eg, region, metropolitan area, ED and hospital type, time and season, and diagnostic and therapeutic procedures) factors. Multivariable logistic regression was performed to identify independent predictors of prolonged ED-LOS. RESULTS: Median ED-LOS for admitted children was 3.7 hours. Thirteen percent of pediatric patients admitted from the ED experienced prolonged ED-LOS. Factors associated with prolonged ED-LOS for admitted children were Hispanic ethnicity (odds ratio [OR], 1.76; 95% confidence interval [95% CI], 1.10-2.81), ED arrival between midnight and 8 a.m. (OR, 2.80; 95% CI, 1.87-4.20), winter season (January-March: OR, 1.81; 95% CI, 1.20-2.74), computed tomography scan or magnetic resonance imaging (OR, 1.65; 95% CI, 1.05-2.58), and intravenous fluids or medications (OR, 1.81; 95% CI, 1.10-2.97). Children requiring ICU admissions (OR, 0.29; 95% CI, 0.11-0.77) or receiving pulse oximetry in the ED (OR, 0.52; 95% CI, 0.34-0.81) had a lower risk of experiencing prolonged ED-LOS. CONCLUSIONS: We found that prolonged ED-LOS occurs frequently for admitted pediatric patients and is associated with Hispanic ethnicity, presentation during winter season, and early morning arrival. Potential strategies to reduce ED-LOS include improved availability of interpreter services and enhanced staffing and additional inpatient bed availability during winter season and overnight hours.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.

BACKGROUND: Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. OBJECTIVE: To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. METHODS: A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. RESULTS: There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01). CONCLUSIONS: Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.