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1.
Pediatrics ; 145(1)2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31882440

RESUMO

BACKGROUND: Provision of high-quality care to acutely ill and injured children is a challenge to US hospitals because many have low pediatric volume. Delineating national trends in definitive pediatric acute care would inform improvements in care. METHODS: We analyzed emergency department (ED) visits by children between 2008 and 2016 in the Nationwide Emergency Department Sample, a weighted sample of 20% of EDs nationally. For each hospital annually, we determined the Hospital Capability Index (HCI) to determine the frequency of definitive acute care, defined as hospitalization instead of ED transfer. Hospitals were classified annually according to 2008 HCI quartiles to understand shifts in pediatric capability. RESULTS: The national median HCI was 0.06 (interquartile range: 0.01-0.17) in 2008 and 0.02 (interquartile range: 0.00-0.09) in 2016 (P < .001). Definitive care became less common regardless of annual pediatric volume, urban or rural designation, or condition frequency. In 2016, 2171 EDs (49.0%) had HCIs <0.013, which represented the lowest 25% of ED HCIs in 2008. Pediatric visits to EDs categorized in the bottom 2008 capability quartile more than doubled from 2.5 million in 2008 to 5.3 million in 2016. Despite decreasing capability, centers with higher annual pediatric volume and urban centers provided more definitive inpatient care and had fewer inter-ED transfers than lower-volume and rural centers. CONCLUSIONS: Across the United States from 2008 to 2016, hospital provision of definitive acute pediatric care decreased, and ED visits to the hospitals least likely to provide definitive care increased. Systems improvements are needed to support hospital-based acute care of children.

2.
Emerg Med J ; 36(12): 736-740, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31597671

RESUMO

BACKGROUND: Delayed diagnoses of serious emergency conditions can lead to morbidity in children, but are challenging to identify and measure. We developed and piloted an automated tool for identifying delayed diagnosis of two serious conditions commonly seen in the ED using administrative data. METHODS: We identified cases with a final diagnosis of appendicitis or sepsis in a freestanding children's hospital from 2008 to 2018, with any hospital ED encounter within the preceding 7 days. Two investigators reviewed a subset of these cases using the electronic health records (EHR) to determine if there was a delayed diagnosis and interrater reliability was assessed using the intraclass correlation coefficient (ICC). An automated tool was applied to the same cases to assess its positive predictive value (PPV) to identify those with a delayed diagnosis, using the manual chart review as the gold standard. The tool used number of days since visit, presence of a related diagnosis on the initial visit, and whether or not the patient was discharged. RESULTS: Previous ED encounters preceded 91/3703 (2.5%) appendicitis cases and 159/1754 (9.1%) sepsis cases; 78 cases of each were sampled for review. In manual review, 73.4% and 22.8% were thought to have delayed diagnoses; reviewer agreement was excellent (appendicitis ICC 0.77, 95% CI 0.62 to 0.86 and sepsis ICC 0.77, 95% CI 0.43 to 0.89). The PPVs of the automated tool for determination of delayed diagnosis for appendicitis within 1, 3 or 7 days were 96.2%, 95.1% and 93.6%, respectively. For sepsis, the PPVs were 71.4%, 63.6% and 41.2% within 1, 3 or 7 days, respectively. CONCLUSIONS: This automated tool performed well compared with expert EHR review. Performance was stronger for appendicitis. Further tool refinement could improve performance.

4.
J Pediatr ; 214: 103-112.e3, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31383471

RESUMO

OBJECTIVES: To define and measure complications across a broad set of acute pediatric conditions in emergency departments using administrative data, and to assess the validity of these definitions by comparing resource utilization between children with and without complications. STUDY DESIGN: Using local consensus, we predefined complications for 16 acute conditions including appendicitis, diabetic ketoacidosis, ovarian torsion, stroke, testicular torsion, and 11 others. We studied patients under age 18 years using 3 data years from the Healthcare Cost and Utilization Project Statewide Databases of Maryland and New York. We measured complications by condition. Resource utilization was compared between patients with and without complications, including hospital length of stay, and charges. RESULTS: We analyzed 27 087 emergency department visits for a serious condition. The most common was appendicitis (n = 16 794), with 24.3% of cases complicated by 1 or more of perforation (24.1%), abscess drainage (2.8%), bowel resection (0.3%), or sepsis (0.9%). Sepsis had the highest mortality (5.0%). Children with complications had higher resource utilization: condition-specific length of stay was longer when complications were present, except ovarian and testicular torsion. Hospital charges were higher among children with complications (P < .05) for 15 of 16 conditions, with a difference in medians from $3108 (testicular torsion) to $13 7694 (stroke). CONCLUSIONS: Clinically meaningful complications were measurable and were associated with increased resource utilization. Complication rates determined using administrative data may be used to compare outcomes and improve healthcare delivery for children.

5.
Clin Pediatr (Phila) ; 58(2): 191-198, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30362824

RESUMO

To understand how parents and physicians make decisions regarding antibiotics and whether a potential associated risk of obesity would alter decisions, we conducted a qualitative study of parents and physicians who care for children. Parent focus groups and physician interviews used a guide focused on experience with antibiotics and perceptions of risks and benefits, including obesity. Content analysis was used to understand how a risk of obesity would influence antibiotic decisions. Most parents (n = 59) and physicians (n = 22) reported limited discussion about any risks at the time of antibiotic prescriptions. With an acute illness, most parents prioritized symptomatic improvement and chose to start antibiotics. Physicians' treatment preferences were varied. An obesity risk did not change most parents' or physicians' preferences. Given that parent-physician discussion at the time of acute illness is unlikely to change preferences, public health messaging may be a more successful approach to counter obesity and antibiotics overuse.


Assuntos
Antibacterianos , Atitude do Pessoal de Saúde , Conhecimentos, Atitudes e Prática em Saúde , Pais/psicologia , Obesidade Pediátrica/psicologia , Médicos/psicologia , Adolescente , Adulto , Tomada de Decisão Clínica , Feminino , Grupos Focais , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Médicos/estatística & dados numéricos , Padrões de Prática Médica , Risco , Adulto Jovem
6.
Pediatrics ; 143(1)2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30559122

RESUMO

OBJECTIVES: Previous analyses of data from 3 large health plans suggested that the substantial downward trend in antibiotic use among children appeared to have attenuated by 2010. Now, data through 2014 from these same plans allow us to assess whether antibiotic use has declined further or remained stable. METHODS: Population-based antibiotic-dispensing rates were calculated from the same health plans for each study year between 2000 and 2014. For each health plan and age group, we fit Poisson regression models allowing 2 inflection points. We calculated the change in dispensing rates (and 95% confidence intervals) in the periods before the first inflection point, between the first and second inflection points, and after the second inflection point. We also examined whether the relative contribution to overall dispensing rates of common diagnoses for which antibiotics were prescribed changed over the study period. RESULTS: We observed dramatic decreases in antibiotic dispensing over the 14 study years. Despite previous evidence of a plateau in rates, there were substantial additional decreases between 2010 and 2014. Whereas antibiotic use rates decreased overall, the fraction of prescribing associated with individual diagnoses was relatively stable. Prescribing for diagnoses for which antibiotics are clearly not indicated appears to have decreased. CONCLUSIONS: These data revealed another period of marked decline from 2010 to 2014 after a relative plateau for several years for most age groups. Efforts to decrease unnecessary prescribing continue to have an impact on antibiotic use in ambulatory practice.


Assuntos
Assistência Ambulatorial/tendências , Antibacterianos/uso terapêutico , Prestação Integrada de Cuidados de Saúde/tendências , Uso de Medicamentos/tendências , Planos de Sistemas de Saúde/tendências , Reembolso de Seguro de Saúde/tendências , Adolescente , Assistência Ambulatorial/métodos , Criança , Pré-Escolar , Prestação Integrada de Cuidados de Saúde/métodos , Feminino , Humanos , Lactente , Masculino , Afiliação Institucional/tendências
7.
Pediatrics ; 142(6)2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-30381474

RESUMO

: media-1vid110.1542/5839981580001PEDS-VA_2018-0290Video Abstract OBJECTIVES: To determine the association of antibiotic use with weight outcomes in a large cohort of children. METHODS: Health care data were available from 2009 to 2016 for 35 institutions participating in the National Patient-Centered Clinical Research Network. Participant inclusion required same-day height and weight measurements at 0 to <12, 12 to <30, and 48 to <72 months of age. We assessed the association between any antibiotic use at <24 months of age with BMI z score and overweight or obesity prevalence at 48 to <72 months (5 years) of age, with secondary assessments of antibiotic spectrum and age-period exposures. We included children with and without complex chronic conditions. RESULTS: Among 1 792 849 children with a same-day height and weight measurement at <12 months of age, 362 550 were eligible for the cohort. One-half of children (52%) were boys, 27% were African American, 18% were Hispanic, and 58% received ≥1 antibiotic prescription at <24 months of age. At 5 years, the mean BMI z score was 0.40 (SD 1.19), and 28% of children had overweight or obesity. In adjusted models for children without a complex chronic condition at 5 years, we estimated a higher mean BMI z score by 0.04 (95% confidence interval [CI] 0.03 to 0.05) and higher odds of overweight or obesity (odds ratio 1.05; 95% CI 1.03 to 1.07) associated with obtaining any (versus no) antibiotics at <24 months. CONCLUSIONS: Antibiotic use at <24 months of age was associated with a slightly higher body weight at 5 years of age.


Assuntos
Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Peso Corporal/efeitos dos fármacos , Peso Corporal/fisiologia , Obesidade Pediátrica/induzido quimicamente , Obesidade Pediátrica/epidemiologia , Índice de Massa Corporal , Pré-Escolar , Estudos de Coortes , Esquema de Medicação , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Obesidade Pediátrica/diagnóstico
9.
Acad Emerg Med ; 25(12): 1355-1364, 2018 12.
Artigo em Inglês | MEDLINE | ID: mdl-29858524

RESUMO

OBJECTIVES: Differences in emergency care for children exist between general and pediatric emergency departments (EDs). Some pediatric quality measures are available but are not routinely employed nationwide. We sought to create a short list of applied measures that would provide a starting point for EDs to measure pediatric emergency care quality and to compare care between general and pediatric EDs for these measures. METHODS: Previously reported lists comprising 465 pediatric emergency care quality measures were reconciled. Preset criteria were used to create a diverse list of quality measures measurable using a national database. We used the National Hospital Ambulatory Medical Care Survey from 2010 to 2015 to measure performance. Measures were excluded for total observation counts under a prespecified power threshold, being unmeasurable in the data set, or for missing clear definitions. Using survey-weighted statistics, we reported summary performance (mean, proportion, or count) with 95% confidence intervals for each analyzed quality measure and compared general and pediatric ED performance. RESULTS: Among 465 quality measures, 28 (6%) were included in the analysis, including seven condition-specific measures and 21 general measures. We analyzed a sample of 36,430 visits corresponding to 179.0 million survey-weighted ED visits, of which 150.8 million (84.3%) were in general EDs. Performance was better in pediatric EDs for three of seven condition-specific measures, including antibiotics for viral infections (-6.2%), chest X-rays for asthma (-18.7%), and topical anesthesia for wound closures (+25.7%). Performance was similar for four of seven condition-specific measures: computed tomography for head trauma, steroids for asthma, steroids for croup, and oral rehydration for dehydration. Compared with pediatric EDs, general EDs discharged and transferred higher proportions of children, had shorter lengths of stay, and sent patients home with fewer prescriptions. General EDs obtained fewer pain scores for injured children. Pediatric EDs had a lower proportion of pediatric visits in which patients left against medical advice. General and pediatric EDs had similar rates of mortality, left without being seen, incomplete vital signs, labs in nonacute patients, and similar numbers of medications given per patient. CONCLUSIONS: Using a national sample of ED visits, we demonstrated the feasibility of using nationally representative data to assess quality measures for children cared for in the ED. Differences between pediatric and general ED care identify targets for quality improvement.


Assuntos
Bases de Dados Factuais , Serviço Hospitalar de Emergência/estatística & dados numéricos , Medicina de Emergência Pediátrica/normas , Adolescente , Criança , Pré-Escolar , Assistência à Saúde/normas , Serviço Hospitalar de Emergência/normas , Feminino , Pesquisas sobre Serviços de Saúde , Hospitais Gerais/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Masculino , Estados Unidos
10.
Pediatrics ; 141(5)2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29650806

RESUMO

BACKGROUND: Emergency department (ED) revisits are used as a measure of care quality. Many EDs measure only revisits to the same facility, underestimating true rates. We sought to determine the frequency, location, and predictors of ED revisits to the same or a different ED. METHODS: We studied ED discharges for children <18 years old in Maryland and New York in the statewide ED and inpatient databases. Revisits were defined as ED visits within 7 days of an index visit. Our primary outcome was the proportion of revisits that were different-hospital revisits (DHRs). We measured the underestimation of total revisits when only same-hospital revisits were measured. We determined the risk of DHR by quartile of annual ED pediatric volume, adjusting for case mix, insurance, state, and urban location. RESULTS: Revisits across 261 EDs occurred after 5.9% of 4.3 million discharges. A per-ED median 21.9% of revisits were DHRs (interquartile range 14.2%-34.6%). Measuring only same-hospital revisits underestimated total revisits by 17.4%. The proportions of revisits that were DHRs by increasing volume quartile were 28.1%, 25.5%, 22.6%, and 14.5%. The adjusted risk of DHR was lower for increasing quartiles of pediatric volume (adjusted odds ratio for highest versus lowest quartile 0.27; 95% confidence interval, 0.19-0.36). CONCLUSIONS: Measuring ED revisits only at the index ED significantly underestimates total revisits. Lower pediatric volume is associated with higher DHRs as a proportion of revisits. When using revisits as a measure of emergency care quality, effort should be made to assess revisits to different EDs.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Distribuição por Idade , Criança , Pré-Escolar , Doença Crônica/epidemiologia , Estudos Transversais , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Lactente , Recém-Nascido , Masculino , Maryland/epidemiologia , Medicaid , New York/epidemiologia , Qualidade da Assistência à Saúde , Estudos Retrospectivos , Fatores de Tempo , Estados Unidos , População Urbana
11.
Acad Pediatr ; 18(5): 569-576, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29477481

RESUMO

OBJECTIVES: The National Patient-Centered Clinical Research Network (PCORnet) supports observational and clinical research using health care data. The PCORnet Antibiotics and Childhood Growth Study is one of PCORnet's inaugural observational studies. We sought to describe the processes used to integrate and analyze data from children across 35 participating institutions, the cohort characteristics, and prevalence of antibiotic use. METHODS: We included children in the cohort if they had at least one same-day height and weight measured in each of 3 age periods: 1) before 12 months, 2) 12 to 30 months, and 3) after 24 months. We distributed statistical queries that each institution ran on its local version of the PCORnet Common Data Model, with aggregate data returned for analysis. We defined overweight or obesity as age- and sex-specific body mass index ≥85th percentile, obesity ≥95th percentile, and severe obesity ≥120% of the 95th percentile. RESULTS: A total of 681,739 children met the cohort inclusion criteria, and participants were racially/ethnically diverse (24.9% black, 17.5% Hispanic). Before 24 months of age, 55.2% of children received at least one antibiotic prescription; 21.3% received a single antibiotic prescription; 14.3% received 4 or more; and 33.3% received a broad-spectrum antibiotic. Overweight and obesity prevalence was 27.6% at age 4 to <6 years (n = 362,044) and 36.2% at 9 to <11 years (n = 58,344). CONCLUSIONS: The PCORnet Antibiotics and Childhood Growth Study is a large national longitudinal observational study in a diverse population that will examine the relationship between early antibiotic use and subsequent growth patterns in children.


Assuntos
Antibacterianos/uso terapêutico , Uso de Medicamentos/estatística & dados numéricos , Sobrepeso/epidemiologia , Estatura , Índice de Massa Corporal , Peso Corporal , Criança , Pré-Escolar , Estudos de Coortes , Feminino , Humanos , Lactente , Estudos Longitudinais , Masculino , Assistência Centrada no Paciente , Estados Unidos/epidemiologia
12.
Pediatr Emerg Care ; 2018 Jan 16.
Artigo em Inglês | MEDLINE | ID: mdl-29346238

RESUMO

OBJECTIVE: The objective of this study was to determine the incidence and recent trends in serious pediatric emergency conditions. METHODS: We conducted a cross-sectional study of the Nationwide Emergency Department Sample from 2008 through 2014, and included patients with age below 18 years with a serious condition, defined as each diagnosis group in the diagnosis grouping system with a severity classification system score of 5. We calculated national incidences for each serious condition using annualized weighted condition counts divided by annual United States census child population counts. We determined the highest-incidence serious conditions over the study period and calculated percentage changes between 2008 and 2014 for each serious condition using a Poisson model. RESULTS: The 2008 incidence of serious conditions across the national child population was 1721 visits per million person-years (95% confidence interval, 1485-1957). This incidence increased to 2020 visits per million person-years (95% confidence interval, 1661-2379) in 2014. The most common serious conditions were serious respiratory diseases, septicemia, and serious neurologic diseases. Anaphylaxis was the condition with the largest change, increasing by 147%, from 101 to 249 visits per million person-years. CONCLUSIONS: The most common serious condition in children presenting to United States emergency departments is serious respiratory disease. Anaphylaxis is the fastest increasing serious condition. Additional research attention to these diagnoses is warranted.

13.
Pediatrics ; 141(2)2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29367204

RESUMO

BACKGROUND AND OBJECTIVES: Pediatric out-of-hospital cardiac arrest (OHCA) has a low rate of survival to hospital discharge. Understanding whether pediatric emergency departments (EDs) have higher survival than general EDs may help identify ways to improve care for all patients with OHCA. We sought to determine if OHCA survival differs between pediatric and general EDs. METHODS: We used the 2009-2014 Nationwide Emergency Department Sample to study children under 18 with cardiac arrest. We compared pediatric EDs (those with >75% pediatric visits) to general EDs on the outcome of survival to hospital discharge or transfer. We determined unadjusted and adjusted survival, accounting for age, region, and injury severity. Analyses were stratified by nontraumatic versus traumatic cause. RESULTS: The incidences of nontraumatic and traumatic OHCA were 7.91 (95% confidence interval [CI]: 7.52-8.30) and 2.67 (95% CI: 2.49-2.85) per 100 000 person years. In nontraumatic OHCA, unadjusted survival was higher in pediatric EDs than general EDs (33.8% vs 18.9%, P < .001). The adjusted odds ratio of survival in pediatric versus general EDs was 2.2 (95% CI: 1.7-2.8). Children with traumatic OHCA had similar survival in pediatric and general EDs (31.7% vs 26.1%, P = .14; adjusted odds ratio = 1.3 [95% CI: 0.8-2.1]). CONCLUSIONS: In a nationally representative sample, survival from nontraumatic OHCA was higher in pediatric EDs than general EDs. Survival did not differ in traumatic OHCA. Identifying the features of pediatric ED OHCA care leading to higher survival could be translated into improved survival for children nationally.


Assuntos
Parada Cardíaca Extra-Hospitalar/mortalidade , Adolescente , Reanimação Cardiopulmonar , Criança , Pré-Escolar , Serviço Hospitalar de Emergência , Feminino , Hospitais Pediátricos , Humanos , Lactente , Masculino , Parada Cardíaca Extra-Hospitalar/terapia , Taxa de Sobrevida , Estados Unidos/epidemiologia
14.
Health Serv Res ; 53(3): 1581-1599, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-28556901

RESUMO

OBJECTIVE: To determine the effect of state-level dependent coverage expansion (DCE) with and without other state health reforms on exit from dependent coverage for adolescents and young adults (AYA). DATA SOURCES: Administrative longitudinal data for 131,542 privately insured AYA in Massachusetts (DCE with other reforms) versus Maine and New Hampshire (DCE without other reforms) across three periods: prereform (1/00-12/06), poststate reform (1/07-9/10), and postfederal reform (10/10-12/12). STUDY DESIGN: A difference-in-differences estimator was used to determine the rate of exit from dependent coverage, age at exit from dependent coverage, and re-uptake of dependent coverage among AYA in states with comprehensive reforms versus DCE only. PRINCIPAL FINDINGS: Implementation of DCE with other reforms was significantly associated with a 23 percent reduction in exit from dependent coverage among AYA compared to the reduction observed for DCE alone. Additionally, comprehensive reforms were associated with over two additional years of dependent coverage for the average AYA and a 33 percent increase in the odds of regaining dependent coverage after a prior loss. CONCLUSIONS: Findings suggest that an individual mandate and other reforms may enhance the effect of DCE in preventing loss of coverage among AYA.


Assuntos
Cobertura do Seguro/legislação & jurisprudência , Cobertura do Seguro/estatística & dados numéricos , Seguro Saúde/legislação & jurisprudência , Seguro Saúde/estatística & dados numéricos , Patient Protection and Affordable Care Act/legislação & jurisprudência , Adolescente , Fatores Etários , Feminino , Humanos , Estudos Longitudinais , Masculino , New England , Estudos Retrospectivos , Fatores Socioeconômicos , Estados Unidos , Adulto Jovem
15.
Pediatrics ; 140(5)2017 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-28978716

RESUMO

BACKGROUND: Rates of invasive pneumococcal disease have declined since widespread introduction of pneumococcal conjugate vaccines (PCVs) in the United States. We evaluated the impact of immunization status and recent antibiotic use on an individual child's risk of colonization. METHODS: This study extends previously reported data from children <7 years of age seen for well child or acute care visits in Massachusetts communities. Nasopharyngeal swabs were collected during 6 surveillance seasons from 2000 to 2014. Parent surveys and medical record reviews confirmed immunization status and recent antibiotic use. We estimated the proportions of children colonized with PCV7-included, additional PCV13-included, and non-PCV13 serotypes. Risk factors for colonization with additional PCV13-included and non-PCV13 serotypes were assessed by using generalized linear mixed models adjusted for clustering by community. RESULTS: Among 6537 children, 19A emerged as the predominant serotype in 2004, with substantial reductions in 2014. Among non-PCV serotypes, 15B/C, 35B, 23B, 11A, and 23A were most common in 2014. We observed greater odds for both additional PCV13 and non-PCV13 colonization in younger children, those with more child care exposure, and those with a concomitant respiratory tract infection. Adjusted odds for additional PCV13 colonization was lower (odds ratio 0.48 [95% confidence interval 0.31-0.75]) among children up-to-date for PCV13 vaccines. Recent antibiotic use was associated with higher odds of additional PCV13 colonization but substantially lower odds of non-PCV13 colonization. CONCLUSIONS: Despite the success of pneumococcal vaccines in reducing colonization and disease due to targeted serotypes, ongoing community-based surveillance will be critical to evaluate the impact of interventions on pneumococcal colonization and disease.


Assuntos
Antibacterianos/uso terapêutico , Vacina Pneumocócica Conjugada Heptavalente/uso terapêutico , Imunização/tendências , Infecções Pneumocócicas/prevenção & controle , Vacinas Pneumocócicas/uso terapêutico , Streptococcus pneumoniae/isolamento & purificação , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino , Massachusetts/epidemiologia , Infecções Pneumocócicas/tratamento farmacológico , Infecções Pneumocócicas/epidemiologia , Sorogrupo , Fatores de Tempo
16.
Pediatrics ; 140(1)2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28646002

RESUMO

BACKGROUND: Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular. METHODS: We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics. RESULTS: Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition. CONCLUSIONS: The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.


Assuntos
Doença Crônica/terapia , Qualidade da Assistência à Saúde/estatística & dados numéricos , Transição para Assistência do Adulto/estatística & dados numéricos , Adolescente , Adulto , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Medicaid , Pais , Estados Unidos
17.
Pediatr Crit Care Med ; 18(4): 370-377, 2017 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28198758

RESUMO

OBJECTIVES: Although medication reconciliation has become standard during hospital admission, rates of unintentional medication discrepancies during intensive care of pediatric patients with chronic disease are unknown. Such discrepancies are an important cause of adverse drug events in adults with chronic illness and are associated with unintentional discontinuation of chronic medications. We sought to determine the rate, type, timing, and predictors of potentially harmful unintentional medication discrepancies in children and young adults with chronic disease. DESIGN: Prospective observational cohort study. SETTING: Patients discharged from the intensive and intermediate care units at a tertiary care children's hospital from September 2013 to May 2014. PATIENTS: Consecutive sample of 308 patients less than 25 years old with chronic disease defined by prescription of at least one predetermined class of chronic medication prior to hospitalization. MEASUREMENTS AND MAIN RESULTS: The number of unintentional medication discrepancies with the potential for harm, as well as patient and medication-related factors predisposing patients to these errors were assessed. Two thousand seven hundred thirty-nine medication discrepancies were identified; 284 (10%) were unintentional and had the potential for harm (0.9/patient). Of these, 128 (45%) were due to errors in taking the preadmission medication history, whereas 156 (55%) were due to errors reconciling the medication history with orders. Most events occurred at admission (66%) and were dosing errors (45%). In multivariable negative binomial regression analyses (adjusted rate ratios [95% CI]), each additional preadmission medication (1.07 [1.04-1.10]), chronic respiratory medications (1.51 [1.01-2.28]), and chronic noninvasive ventilation (1.53 [1.07-2.19]) were associated with increased risk of a discrepancy. CONCLUSIONS: Unintentional medication discrepancies with the potential for harm are common among children and young adults with chronic disease during critical care admission due to both failure to obtain an accurate medication history and errors in reconciling the history with patient orders. The use of current medication reconciliation processes is insufficient to prevent errors in this high-risk population.


Assuntos
Doença Crônica/terapia , Cuidados Críticos/normas , Reconciliação de Medicamentos/estatística & dados numéricos , Adolescente , Criança , Pré-Escolar , Cuidados Críticos/estatística & dados numéricos , Feminino , Hospitais Pediátricos/normas , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Pediátrica/normas , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Massachusetts , Erros de Medicação/estatística & dados numéricos , Modelos Estatísticos , Análise Multivariada , Near Miss/estatística & dados numéricos , Estudos Prospectivos , Adulto Jovem
18.
Child Obes ; 13(1): 36-43, 2017 02.
Artigo em Inglês | MEDLINE | ID: mdl-27680585

RESUMO

OBJECTIVES: A number of states have enacted regulations to increase physical activity in children attending child care, but most were not evaluated. In 2010, Massachusetts (MA) enacted a new regulation requiring 60 minutes of light, moderate, and vigorous physical activity (LMVPA) for children in child care; we conducted a prospective evaluation. We hypothesized that MA centers would comply with the regulation at follow-up, resulting in increases in children's LMVPA. METHODS: We evaluated compliance with the regulation in MA using Rhode Island (RI) as the comparison. We measured physical activity in a longitudinal sample of 20 centers and cross-sectional samples of 180 children per state three times before and three times after the regulation took effect. We assessed physical activity using the Observation System for Recording Activity in Preschoolers. We conducted difference-in-differences tests to evaluate changes in LMVPA in MA compared with RI from baseline to follow-up. RESULTS: Children were active for at least 60 minutes of LMVPA in over 80% of centers at baseline and follow-up in MA and RI. Nevertheless, LMVPA increased in both states. In multivariable adjusted regressions, LMVPA increased from baseline to follow-up [MA estimate 38.1 minutes; confidence interval (CI): 28.6, 47.5; p ≤ 0.0001; and RI estimate 42.7 minutes; CI: 35.2, 50.1; p ≤ 0.0001]. The average difference-in-differences estimate indicated no difference in MA compared with RI (estimate -4.6 minutes; CI: -16.6, 7.5; p = 0.46) since LMVPA increased comparably in both states. CONCLUSIONS: Although LMVPA increased in MA, we observed similar changes in RI. Thus, other factors could have influenced children's physical activity.


Assuntos
Cuidado da Criança/legislação & jurisprudência , Creches/legislação & jurisprudência , Exercício , Acelerometria , Creches/estatística & dados numéricos , Pré-Escolar , Estudos Transversais , Metabolismo Energético , Grupos Étnicos , Humanos , Massachusetts , Estudos Prospectivos , Rhode Island , Fatores de Tempo
19.
JAMA ; 315(17): 1864-73, 2016 May 03.
Artigo em Inglês | MEDLINE | ID: mdl-27139059

RESUMO

IMPORTANCE: The National Action Plan for Combating Antibiotic-Resistant Bacteria set a goal of reducing inappropriate outpatient antibiotic use by 50% by 2020, but the extent of inappropriate outpatient antibiotic use is unknown. OBJECTIVE: To estimate the rates of outpatient oral antibiotic prescribing by age and diagnosis, and the estimated portions of antibiotic use that may be inappropriate in adults and children in the United States. DESIGN, SETTING, AND PARTICIPANTS: Using the 2010-2011 National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, annual numbers and population-adjusted rates with 95% confidence intervals of ambulatory visits with oral antibiotic prescriptions by age, region, and diagnosis in the United States were estimated. EXPOSURES: Ambulatory care visits. MAIN OUTCOMES AND MEASURES: Based on national guidelines and regional variation in prescribing, diagnosis-specific prevalence and rates of total and appropriate antibiotic prescriptions were determined. These rates were combined to calculate an estimate of the appropriate annual rate of antibiotic prescriptions per 1000 population. RESULTS: Of the 184,032 sampled visits, 12.6% of visits (95% CI, 12.0%-13.3%) resulted in antibiotic prescriptions. Sinusitis was the single diagnosis associated with the most antibiotic prescriptions per 1000 population (56 antibiotic prescriptions [95% CI, 48-64]), followed by suppurative otitis media (47 antibiotic prescriptions [95% CI, 41-54]), and pharyngitis (43 antibiotic prescriptions [95% CI, 38-49]). Collectively, acute respiratory conditions per 1000 population led to 221 antibiotic prescriptions (95% CI, 198-245) annually, but only 111 antibiotic prescriptions were estimated to be appropriate for these conditions. Per 1000 population, among all conditions and ages combined in 2010-2011, an estimated 506 antibiotic prescriptions (95% CI, 458-554) were written annually, and, of these, 353 antibiotic prescriptions were estimated to be appropriate antibiotic prescriptions. CONCLUSIONS AND RELEVANCE: In the United States in 2010-2011, there was an estimated annual antibiotic prescription rate per 1000 population of 506, but only an estimated 353 antibiotic prescriptions were likely appropriate, supporting the need for establishing a goal for outpatient antibiotic stewardship.


Assuntos
Assistência Ambulatorial/estatística & dados numéricos , Antibacterianos/uso terapêutico , Prescrição Inadequada/estatística & dados numéricos , Otite Média Supurativa/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Faringite/tratamento farmacológico , Prevalência , Infecções Respiratórias/tratamento farmacológico , Estados Unidos
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