Improving Bronchiolitis Care in Outpatient Settings Across a Health Care System.

OBJECTIVE: This study aimed (1) to reduce use of ineffective testing and therapies in children with bronchiolitis across outpatient settings in a large pediatric health care system and (2) to assess the cost impact and sustainability of these initiatives. METHODS: We designed a system-wide quality improvement project for patients with bronchiolitis seen in 3 emergency departments (EDs) and 5 urgent care (UC) centers. Interventions included development of a best-practice guideline and education of all clinicians (physicians, nurses, and respiratory therapists), ongoing performance feedback for physicians, and a small physician financial incentive. Measures evaluated included use of chest x-ray (CXR), albuterol, viral testing, and direct (variable) costs. Data were tracked using statistical process control charts. RESULTS: For 3 bronchiolitis seasons, albuterol use decreased from 54% to 16% in UC and from 45% to 16% in ED. Chest x-ray usage decreased from 29% to 9% in UC and from 21% to 12% in the ED. Viral testing in UC decreased from 18% to 2%. Cost of care was reduced by $283,384 within our system in the first 2 seasons following guideline implementation. Improvements beginning in the first bronchiolitis season were sustained and strengthened in the second and third seasons. Admissions from the ED and admissions after return to the ED within 48 hours of initial discharge did not change. CONCLUSION: A system-wide quality improvement project involving multiple outpatient care settings reduced the use of ineffective therapies and interventions in patients with bronchiolitis and resulted in significant cost savings. Improvements in care were sustained for 3 bronchiolitis seasons.

Progress (?) Toward Reducing Pediatric Readmissions.

Many children's hospitals are actively working to reduce readmissions to improve care and avoid financial penalties. We sought to determine if pediatric readmission rates have changed over time. We used data from 66 hospitals in the Inpatient Essentials Database including index hospitalizations from January, 2010 through June, 2016. Seven-day all cause (AC) and potentially preventable readmission (PPR) rates were calculated using 3M PPR software. Total and condition-specific quarterly AC and PPR rates were generated for each hospital and in aggregate. We included 4.52 million hospitalizations across all study years. Readmission rates did not vary over the study period. The median seven-day PPR rate across all quarters was 2.5% (range 2.1%-2.5%); the median seven-day AC rate across all quarters was 5.1% (range 4.3%-5.3%). Readmission rates for individual conditions fluctuated. Despite significant national efforts to reduce pediatric readmissions, both AC and PPR readmission rates have remained unchanged over six years.

Children's Hospital Characteristics and Readmission Metrics.

BACKGROUND AND OBJECTIVE: Like their adult counterparts, pediatric hospitals are increasingly at risk for financial penalties based on readmissions. Limited information is available on how the composition of a hospital's patient population affects performance on this metric and hence affects reimbursement for hospitals providing pediatric care. We sought to determine whether applying different readmission metrics differentially affects hospital performance based on the characteristics of patients a hospital serves. METHODS: We performed a cross-sectional analysis of 64 children's hospitals from the Children's Hospital Association Case Mix Comparative Database 2012 and 2013. We calculated 30-day observed-to-expected readmission ratios by using both all-cause (AC) and Potentially Preventable Readmissions (PPR) metrics. We examined the association between observed-to-expected rates and hospital characteristics by using multivariable linear regression. RESULTS: We examined a total of 1 416 716 hospitalizations. The mean AC 30-day readmission rate was 11.3% (range 4.3%-19.6%); the mean PPR rate was 4.9% (range 2.9%-6.9%). The average 30-day AC observed-to-expected ratio was 0.96 (range 0.63-1.23), compared with 0.95 (range 0.65-1.23) for PPR; 59% of hospitals performed better than expected on both measures. Hospitals with higher volumes, lower percentages of infants, and higher percentage of patients with low income performed worse than expected on PPR. CONCLUSIONS: High-volume hospitals, those that serve fewer infants, and those with a high percentage of patients from low-income neighborhoods have higher than expected PPR rates and are at higher risk of reimbursement penalties.

Preventability of Pediatric 30-Day Readmissions following Ventricular Shunt Surgery.

OBJECTIVE: To compare the preventability of 30-day pediatric ventricular shunt readmissions using clinical and administrative data review. STUDY DESIGN: We performed a retrospective chart review of one hundred forty-seven 30-day ventricular shunt readmissions at a tertiary pediatric center from May 2009-April 2013 under 2 scenarios: scenario 1 considered all ventricular shunt failures preventable; and scenario 2 considered shunt failures with excellent/good catheter positioning and no contributing deficiencies in care not preventable. Three physician reviewers independently assessed readmissions to determine their preventability and whether deficiencies in care existed that contributed to the readmission. We also evaluated the degree of interrater agreement in adjudicating readmission preventability. RESULTS: Only 42% of 30-day readmissions following ventricular shunt procedures were preventable when considering all shunt failures as preventable. When classifying shunts with excellent/good proximal catheter position as not preventable, 21% of ventricular shunt readmissions were deemed preventable. Interrater agreement on readmission preventability was high (kappa 0.88). Deficiencies in care existed in 29 readmissions (20%), the largest category being physician related, but not all deficiencies contributed to a readmission. CONCLUSIONS: Significant discrepancy exists in the preventability adjudication of ventricular shunt readmissions between administrative and chart review. Although using administrative data has determined that a majority of readmissions following pediatric ventricular shunt procedures are preventable, our review suggests a significantly lower degree of preventability.

Cloud-based Predictive Modeling System and its Application to Asthma Readmission Prediction.

The predictive modeling process is time consuming and requires clinical researchers to handle complex electronic health record (EHR) data in restricted computational environments. To address this problem, we implemented a cloud-based predictive modeling system via a hybrid setup combining a secure private server with the Amazon Web Services (AWS) Elastic MapReduce platform. EHR data is preprocessed on a private server and the resulting de-identified event sequences are hosted on AWS. Based on user-specified modeling configurations, an on-demand web service launches a cluster of Elastic Compute 2 (EC2) instances on AWS to perform feature selection and classification algorithms in a distributed fashion. Afterwards, the secure private server aggregates results and displays them via interactive visualization. We tested the system on a pediatric asthma readmission task on a de-identified EHR dataset of 2,967 patients. We conduct a larger scale experiment on the CMS Linkable 2008-2010 Medicare Data Entrepreneurs' Synthetic Public Use File dataset of 2 million patients, which achieves over 25-fold speedup compared to sequential execution.

Impact of audit and feedback and pay-for-performance interventions on pediatric hospitalist discharge communication with primary care providers.

The study team sought to improve hospitalist communication with primary care providers (PCPs) at discharge through interventions consisting of (a) audit and feedback and (b) inclusion of a discharge communication measure in the incentive compensation for pediatric hospitalists. The setting was a 16-physician pediatric hospitalist group within a tertiary pediatric hospital. Discharge summaries were selected randomly for documentation of communication with PCPs. At baseline, 57% of charts had documented communication with PCPs, increasing to 84% during the audit and feedback period. Following the addition of a financial incentive, documentation of communication with PCPs increased to 93% and was sustained during the combined intervention period. The number of physicians meeting the study's performance goal increased from 1 to 14 by the end of the study period. A financial incentive coupled with an audit and feedback tool was effective at modifying physician behavior, achieving focused, measurable quality improvement gains.

Rates and impact of potentially preventable readmissions at children's hospitals.

OBJECTIVE: To assess readmission rates identified by 3M-Potentially Preventable Readmissions software (3M-PPRs) in a national cohort of children's hospitals. STUDY DESIGN: A total of 1 719 617 hospitalizations for 1 531 828 unique patients in 58 children's hospitals from 2009 to 2011 from the Children's Hospital Association Case-Mix Comparative database were examined. Main outcome measures included rates, diagnoses, and costs of potentially preventable readmissions (PPRs) and all-cause readmissions. RESULTS: The 7-, 15-, and 30-day rates by 3M-PPRs were 2.5%, 4.1%, and 6.2%, respectively. Corresponding all-cause readmission rates were 5.0%, 8.7%, and 13.3%. At 30 days, 60.6% of all-cause readmissions were considered nonpreventable by 3M-PPRs, more than one-half of which were related to malignancies. The percentage of readmissions rated as potentially preventable was similar at all 3 time intervals. Readmissions after chemotherapy, acute leukemia, and cystic fibrosis were all considered nonpreventable, and at least 80% of readmissions after index admissions for sickle cell crisis, bronchiolitis, ventricular shunt procedures, asthma, and appendectomy were designated potentially preventable. Total costs for all readmissions were $1.7 billion; PPRs accounted for 27.3% of these costs. The most costly readmissions were associated with ventricular shunt procedures ($26.5 million/year), seizures ($15.5 million/year), and sickle cell crisis ($15.0 million/year). CONCLUSIONS: Rates of PPRs were significantly lower than all-cause readmission rates more than one-half of which were caused by exclusion of malignancies. Annual costs of PPRs, although significant in the aggregate, appear to represent a much smaller cost-savings opportunity for children than for adults. Our study may help guide children's hospitals to focus readmission reduction strategies on areas where the financial vulnerability is greatest based on 3M-PPRs.

Prevalence and predictors of return visits to pediatric emergency departments.

OBJECTIVE: To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING: Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS: Patients <18 years old discharged following an ED visit. MEASURES: The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. RESULTS: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7-2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS: Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization.

Return to system within 30 days of discharge following pediatric shunt surgery.

OBJECT: The rate of readmission after CSF shunt surgery is significant and has caught the attention of purchasers of health care. However, a detailed description of clinical scenarios that lead to readmissions and reoperations after index shunt surgery is lacking in the medical literature. METHODS: This study included 1755 shunt revision and insertion surgeries that were performed at a single institution between May 1, 2009, and April 30, 2013. Demographic, socioeconomic, and clinical characteristics were prospectively collected in the administrative, business, and operating room databases. Clinical events within the 30 days following discharge were reviewed and analyzed. Two events of interest, Emergency Department (ED) utilization and reoperation, were further analyzed for risk factor associations by using multivariate logistic regression. RESULTS: There were 290 readmissions within 30 days of discharge (16.5%). Admission sources included ED (n = 216), hospital transfers (n = 23), and others. Of the 290 readmissions, 184 were associated with an operation, but only 165 of these were performed by the neurosurgical service. These included surgeries for shunt occlusion and externalization (n = 150), wound revision (n = 7), and other neurosurgical procedures that were not shunt related (n = 8). The remaining readmissions (n = 106) were not associated with an operation, and only 59 patients were admitted for issues related to the index shunt surgery. When return to the ED was the dependent variable in a multivariate regression model, patients who returned to the ED were more likely to be from the Atlanta metropolitan area and to be either uninsured or insured with public assistance. When reoperation was the dependent variable, patients whose surgery started after 3 p.m. were more likely to undergo subsequent CSF shunt revision surgery on readmission. CONCLUSIONS: Of the readmissions within 30 days of shunt surgery, 74.5% were related to the index shunt surgery. Whether and to what extent these readmissions are preventable continues to be controversial. Further study is needed to identify modifiable risk factors that may eventually improve patient care.

Anaplastic pseudothyroiditis.

Anaplastic thyroid carcinoma (ATC) is one of the most aggressive solid tumours. It generally presents as a rapidly enlarging thyroid mass and produces local symptoms associated with mass effect. One of the very rare presentations of ATC is thyrotoxicosis. We report a patient with ATC whose course was complicated by severe thyrotoxicosis. His symptoms were controlled with beta-blockers. Two weeks into hospitalization, the patient became hypothyroid. Histopathology showed destruction of the normal thyroid follicles by the invasion of the tumour. As this form of thyrotoxicosis resembles various thyroiditides, we hereby refer this condition as "anaplastic pseudothyroiditis".