Paranasal Mass in a Healthy Male Toddler.

Head and neck tumors are rare in pediatric patients but should be kept in the differential when a patient presents with a new swelling or mass. One of these tumors is a myxoma, which is an insidiously growing, benign mass originating from the mesenchyme. They most commonly arise in the myocardium but can also develop in facial structures, particularly in the maxilla and mandible. When arising in facial structures, ocular, respiratory, and digestive systems can be affected based on local invasion. Complete surgical resection is curative but can lead to significant morbidity as well. Here, we present a case of a 15-month-old toddler presenting with a paranasal mass, which was ultimately diagnosed as a maxillary myxoma. This tumor is very rare in the pediatric population, especially in the toddler age-group, reminding clinicians to broaden the differential diagnosis when a patient's course is atypical.

Do the Guidelines Apply?-A Multisite, Combined Stakeholder Qualitative Case Study to Understand Care Decisions in Bronchiolitis.

BACKGROUND: Clinical practice guidelines for bronchiolitis recommend against tests and treatments that do not improve outcomes, yet most children admitted with bronchiolitis continue to receive them. An improved understanding of factors that influence care decisions across multiple stakeholders and diverse settings is needed to develop effective strategies to de-implement (or reduce) unnecessary testing and treatment. METHODS: We explored health care provider, care team, and parent perspectives on testing and treatment in bronchiolitis to develop a combined stakeholder account of care decisions. We conducted a qualitative case study across 2 geographically distinct university affiliated children's hospitals representing a generally low and high test/treatment utilizing hospital respectively from March 2019 to May 2020. We conducted 46 semistructured interviews and 3 focus groups with a total of 74 participants. Data were analyzed using applied thematic analysis and findings were triangulated across participant group and data collection method. RESULTS: Three themes emerged around care decisions: 1) awareness and perceptions of the guidelines or evidence; 2) perceptions of expected tests or treatments, and 3) organizational culture and existing care processes. Provider and care team participants commonly described parent expectations as drivers of utilization. Conversely, parents generally reported a lack of expectations for tests/treatments and that tests/treatments did not improve their experience of care. CONCLUSIONS: This study illuminated factors associated with the differential adoption of evidence and targets for future de-implementation strategies. Importantly, incongruent with provider and care team perceptions, parents reported that they desire an evidence-based, less-is-more approach to bronchiolitis care.

Quality Improvement-Driven Reduction in Countywide Medicaid Acute Asthma Health Care Utilization.

OBJECTIVE: This study evaluates the impact of a coordinated effort by an urban pediatric hospital and its associated accountable care organization to reduce asthma-related emergency department (ED) and inpatient utilization by a large, countywide Medicaid patient population. METHODS: Multiple evidence-based interventions targeting general pediatric asthma care and high health care utilizers were implemented using standardized quality improvement methodologies. Annual asthma ED and inpatient utilization rates by 2- to 18-year-old members of an accountable care organization living in the surrounding county (>140,000 eligible members in 2016), adjusted per 1000 children from 2008 through 2016, were analyzed using Poisson regression. We compared these ED utilization rates to national rates from 2006 to 2014. RESULTS: Asthma ED utilization fell from 18.1 to 12.9 visits/1000 children from 2008 to 2016, representing a 28.7% reduction, with an average annual decrease of 3.9% (P < .001), during a time when national utilization was increasing. Asthma inpatient utilization did not change significantly during the study period. CONCLUSIONS: Asthma-related ED utilization was significantly reduced in a large population of primarily urban, minority, Medicaid-insured children by implementing a multimodal asthma quality improvement program. With adequate support, a similar approach could be successful in other communities.

Hospital-level compliance with asthma care quality measures at children's hospitals and subsequent asthma-related outcomes.

CONTEXT: The Children's Asthma Care (CAC) measure set evaluates whether children admitted to hospitals with asthma receive relievers (CAC-1) and systemic corticosteroids (CAC-2) and whether they are discharged with a home management plan of care (CAC-3). It is the only Joint Commission core measure applicable to evaluate the quality of care for hospitalized children. OBJECTIVES: To evaluate longitudinal trends in CAC measure compliance and to determine if an association exists between compliance and outcomes. DESIGN, SETTING, AND PATIENTS: Cross-sectional study using administrative data and CAC compliance data for 30 US children's hospitals. A total of 37,267 children admitted with asthma between January 1, 2008, and September 30, 2010, with follow-up through December 31, 2010, accounted for 45,499 hospital admissions. Hospital-level CAC measure compliance data were obtained from the National Association of Children's Hospitals and Related Institutions. Readmission and postdischarge emergency department (ED) utilization data were obtained from the Pediatric Health Information System. MAIN OUTCOME MEASURES: Children's Asthma Care measure compliance trends; postdischarge ED utilization and asthma-related readmission rates at 7, 30, and 90 days. RESULTS: The minimum quarterly CAC-1 and CAC-2 measure compliance rates reported by any hospital were 97.1% and 89.5%, respectively. Individual hospital CAC-2 compliance exceeded 95% for 97.9% of the quarters. Lack of variability in CAC-1 and CAC-2 compliance precluded examination of their association with the specified outcomes. Mean CAC-3 compliance was 40.6% (95% CI, 34.1%-47.1%) and 72.9% (95% CI, 68.8%-76.9%) for the initial and final 3 quarters of the study, respectively. The mean 7-, 30-, and 90-day postdischarge ED utilization rates were 1.5% (95% CI, 1.3%-1.6%), 4.3% (95% CI, 4.0%-4.5%), and 11.1% (95% CI, 10.5%-11.7%) and the mean quarterly 7-, 30-, and 90-day readmission rates were 1.4% (95% CI, 1.2%-1.6%), 3.1% (95% CI, 2.8%-3.3%), and 7.6% (95% CI, 7.2%-8.1%). There was no significant association between overall CAC-3 compliance (odds ratio [OR] for 5% improvement in compliance) and postdischarge ED utilization rates at 7 days (OR, 1.00; 95% CI, 0.98-1.02), 30 days (OR, 0.97; 95% CI, 0.90-1.04), and 90 days (OR, 0.96; 95% CI, 0.77-1.18). In addition, there was no significant association between overall CAC-3 compliance (OR for 5% improvement in compliance) and readmission rates at 7 days (OR, 1.00; 95% CI, 0.99-1.02), 30 days (OR, 0.99; 95% CI, 0.96-1.02), and 90 days (OR, 1.01; 95% CI, 0.90-1.12). CONCLUSION: Among children admitted to pediatric hospitals for asthma, there was high hospital-level compliance with CAC-1 and CAC-2 quality measures and moderate compliance with the CAC-3 measure but no association between CAC-3 compliance and subsequent ED visits and asthma-related readmissions.