RESUMO
This article describes an innovative asthma quality improvement initiative conducted in school-based health centers (SBHCs) with collaboration among multiple community partners including the children's hospital, a federally qualified health center, the health department, the public school, and parents of children with asthma. The aim was to improve the health of children with asthma in these schools, as measured by minimal asthma-related activity restriction and reduction in asthma-related emergency department (ED) visits. Process measures tracked included the percent of children with (1) asthma severity classified, (2) persistent asthma with controller medication prescribed, and (3) written care plans. Data supported a statistically significant decreasing trend for the percent of SBHC children reporting activity restriction due to asthma. In addition, trend analysis demonstrated a statistically significant difference in ED visits for asthma in the SBHC group compared with a non-SBHC group. Improvements were demonstrated for all process measures. Factors contributing to success included emphasis on community engagement, transparency in sharing ideas and results, benefits outweighing human resource costs of participating, readily available data to drive improvement, and the use of multiple intervention strategies.
Assuntos
Asma , Serviços de Saúde Comunitária/normas , Qualidade da Assistência à Saúde/normas , Serviços de Saúde Escolar/normas , Instituições Acadêmicas , Estudantes , Adolescente , Asma/terapia , Criança , Feminino , Promoção da Saúde , Humanos , Masculino , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Estados UnidosRESUMO
STUDY OBJECTIVES: The purpose of this study was to determine the impact of a multisite implementation of an evidence-based clinical practice guideline for bronchiolitis. DESIGN: Before and after study. SETTING: Eleven Child Health Accountability Initiative (CHAI) study hospitals. PATIENTS: Children < 12 months of age with a first-time episode of bronchiolitis. INTERVENTION: The guideline was implemented in December 1998. Complete preimplementation and postimplementation administrative data on hospital admissions, resource utilization, and length of stay were available from seven study hospitals. At five sites, chart reviews were conducted for data on the number and type of bronchodilators used. MEASUREMENTS AND RESULTS: Complete administrative data were available for 846 historical control subjects and 792 study patients. Length of stay decreased significantly. While the proportion of eligible patients who received any bronchodilator did not change (84%), the proportion of patients who received albuterol decreased from 80 to 75% after guideline implementation (p < 0.03). For patients who received bronchodilators, the mean (+/- SD) number of doses decreased from 13.6 +/- 14.0 to 7.3 +/- 9.1 doses (p < 0.0001). For patients who received albuterol, the mean number of doses decreased from 12.8 +/- 11.8 to 6.4 +/- 7.8 doses (p < 0.0001). Other resource use decreased modestly. Hospital readmission rates within 7 days of discharge were unchanged. CONCLUSIONS: We successfully extended the implementation of an evidence-based clinical practice guideline from one hospital to seven hospitals. Within just a single bronchiolitis season, some significant changes in practice were seen. The multisite CHAI collaborative appears to be a promising laboratory for large-scale quality improvement initiatives.
Assuntos
Bronquiolite/terapia , Fidelidade a Diretrizes , Broncodilatadores/uso terapêutico , Humanos , LactenteRESUMO
OBJECTIVE: To compare the health-related quality of life (HRQOL) of people with cystic fibrosis (CF) to the general population, and to determine the relationship between HRQOL and clinical and demographic factors. DESIGN: Cross-sectional analysis of observational cohort. SETTING: Outpatient clinics of a Midwestern CF center. SUBJECTS: One hundred sixty-two subjects with CF aged 5 to 45 years. MAIN OUTCOME MEASURES: Physical and psychosocial summary scores and individual scale scores for the Child Health Questionnaire and Short Form-36. RESULTS: Compared with the general population, people with CF reported similar scores for most psychosocial measures, but lower scores for most physical measures, with the lowest scores on the general health perceptions scale. In multivariable analyses, pulmonary exacerbations in the past 6 months were strongly associated with the physical (p = 0.001) and psychosocial (p = 0.0003) scores. The physical score fell, on average, 6 points per exacerbation and the psychosocial score fell 3 points. Lung function, nutrition, 6-min walk distance, age, gender, and insurance status were not significantly associated with HRQOL in this study population. Those who declined to participate had significantly lower FEV(1) percent predicted and nutritional indexes. Our findings may not be generalizable to the entire CF population. CONCLUSION: Recent pulmonary exacerbations have a profound negative impact on HRQOL that is not explained by differences in lung function, nutritional status, or demographic factors.
Assuntos
Fibrose Cística/psicologia , Qualidade de Vida , Adaptação Psicológica , Adolescente , Adulto , Criança , Pré-Escolar , Fibrose Cística/diagnóstico , Progressão da Doença , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação Nutricional , Papel do DoenteRESUMO
BACKGROUND: Excessive and inappropriate use of antibiotics has been identified as a leading cause of the emergence of multiply resistant strains of pneumococci. OBJECTIVE: To examine the effects of academic detailing and a parental education program on community pediatricians' prescription of antibiotics for young children. METHODS: Physician leaders in study practices prepared educational modules and presented the modules to their practices. The control groups received only practice-specific report cards. Using a time-series analysis, we collected data on office visits and antibiotic prescriptions filled between May 1, 2000, and April 30, 2001 (baseline period), and between May 1, 2001, and April 30, 2002 (intervention period). Antibiotic prescription rate was defined as the ratio of antibiotic prescriptions filled to the number of office visits. RESULTS: The antibiotic prescription rate decreased to 0.82 (95% confidence interval, 0.71-0.95) of the baseline rate for the study group (6 practices) and to 0.86 (95% confidence interval, 0.77-0.95) of the baseline for the control group (5 practices). Similar patterns for antibiotic prescription rates were seen for study and control groups both before and after the intervention. Wide variations in prescription rates were observed among the practices, but, in general, the control practices had lower antibiotic prescribing rates during both the baseline and the intervention periods. Use of amoxicillin increased slightly in the study group and decreased slightly in the control group. The use of cephalosporins increased slightly in both groups. CONCLUSION: Overall, academic detailing appeared to be no more effective in reducing antibiotic use than the practice-specific report cards alone.
Assuntos
Antibacterianos/uso terapêutico , Serviços de Saúde Comunitária/tendências , Prescrições de Medicamentos/estatística & dados numéricos , Pediatria/tendências , Padrões de Prática Médica/tendências , Criança , Pré-Escolar , Serviços de Saúde Comunitária/estatística & dados numéricos , Uso de Medicamentos/estatística & dados numéricos , Feminino , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Mau Uso de Serviços de Saúde/tendências , Humanos , Masculino , Visita a Consultório Médico/estatística & dados numéricos , Ohio , Pediatria/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde , Estações do AnoRESUMO
OBJECTIVE: To examine the relationship between the use and type of primary care and visits to the emergency department (ED) in early infancy by healthy infants who are Medicaid recipients. DESIGN: A population-based cohort study using a database linking birth certificate data to Medicaid claims. PARTICIPANTS: A total of 151 464 full-term infants born in Ohio to mothers receiving Medicaid from July 1, 1991, through June 30, 1998. MAIN OUTCOME MEASURES: The primary outcome of interest was the occurrence of an ED visit within 91 days of the neonate's birth. Bivariate and multivariate analyses were performed to determine the effect of early linkage with primary care (within 21 days of birth) on ED use in early infancy. RESULTS: Only 53% of the infants had a documented primary care visit within 21 days of birth. Twenty-eight percent of infants had at least 1 ED visit within 91 days of birth and 9% had more than 1 visit. The mean age of the neonate at the first ED visit was 39.7 days. Fifteen percent of primary care visits within 21 days of birth occurred at a hospital-based primary care clinic. After adjusting for maternal, infant, and residency characteristics and temporal differences, early primary care linkage was associated with a 16% increase in the likelihood of ED use. When the primary care visit occurred in a hospital-based primary care clinic, it was associated with a 27% increase in the likelihood of ED use. CONCLUSION: Contrary to our expectations, early primary care linkage did not result in a decreased risk of ED use.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Cuidado Pós-Natal/estatística & dados numéricos , Cuidado Pré-Natal/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Humanos , Lactente , Cuidado do Lactente/estatística & dados numéricos , Recém-Nascido , Medicaid/estatística & dados numéricos , Análise Multivariada , Ohio/epidemiologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Our objective was to determine the magnitude and direction of differences between adolescents with cystic fibrosis (CF) and their parents' reports of the adolescents' health-related quality of life (HRQOL) as measured by the adolescent and parent versions of the Child Health Questionnaire (CHQ). Sixty-two adolescents (mean age, 13.7 years; 46% female; mean forced expired volume in 1 sec, 73%) completed the 87-item adolescent form, and their parents (79% mothers; 77% working full or part time) completed the 50-item parent form of the CHQ during a routine clinic visit. For each scale, ANOVA was used to determine pairwise differences between adolescent and parent scale scores. For scales in which a significant parent-adolescent difference existed, ANCOVA was used to determine disease and demographic factors independently associated with differences in scores. Finally, responses for each pair were compared only on similarly worded items within each scale. For the full CHQ scales, adolescents rated their HRQOL significantly better than did their parents with regard to General Health (mean difference, 12.4 points), Role Function/Physical (mean difference, 9.0 points), Behavior (mean difference, 4.8 points), and Physical Function (mean difference, 4.0 points). No demographic or health factor was associated consistently with differences in parent-adolescent scores. When only similarly worded items were compared, adolescents still tended to rate their HRQOL better, but the difference was significant only for General Health (P = 0.0005), where adolescents rated themselves less susceptible to illness and less worried about their health than their parents. In conclusion, optimal measurement of adolescent HRQOL will likely require determining both parent and adolescent perceptions of HRQOL.
Assuntos
Fibrose Cística/psicologia , Qualidade de Vida , Perfil de Impacto da Doença , Adolescente , Análise de Variância , Criança , Fibrose Cística/fisiopatologia , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pais/psicologia , Inquéritos e QuestionáriosRESUMO
Appendicitis is a frequent pediatric surgical condition for which there is great variability among practitioners regarding diagnosis and postoperative management. With this in mind, the authors designed and implemented an evidence-based appendicitis clinical pathway at their institution. Establishment of the pathway resulted in decreased hospital cost, reduced hospital stay, and fewer unnecessary laboratory tests. The purpose of the current study was to determine the sustainability of the pathway beyond its initial implementation phase. The authors showed that several, but not all, favorable outcomes of the pathway were sustained. These data suggest that a clinical pathway for appendicitis at the authors' institution results in sustained beneficial effects in some but not all outcome parameters. Ongoing monitoring of pathway compliance, continued education of practitioners and nursing personnel, and identification of key pathway team member(s) responsible for the pathway system might result in a greater long-term impact of these guidelines.
Assuntos
Apendicite/cirurgia , Procedimentos Clínicos , Avaliação de Resultados em Cuidados de Saúde , Apendicite/diagnóstico , Criança , Medicina Baseada em Evidências , Feminino , Custos Hospitalares , Humanos , Perfuração Intestinal/cirurgia , Tempo de Internação , Modelos Lineares , Masculino , Ohio , Cuidados Pós-Operatórios , Ruptura EspontâneaRESUMO
OBJECTIVE: To use quality-improvement (QI) methods to develop and test a multimodal intervention to improve hand-hygiene compliance among health care workers (HCWs) to >90%. METHODS: We used a quasi-experimental staggered intervention that was conducted on 2 similar general pediatric units within a 475-bed tertiary children's hospital. Compliance was defined as acceptable hand hygiene both before and after contact with the patient or the patient's care environment. Measurement of HCW hand-hygiene compliance was performed by covert observations made during routine patient care. Twelve months of preintervention data were collected. QI methods were used to test and implement interventions sequentially in each unit. Interventions addressed leadership support, improving HCW knowledge, hand-hygiene supply availability, and HCW behavior. RESULTS: Interventions began on unit A on November 10, 2008. Similar interventions were later tested on unit B starting March 23, 2009. By April 1, 2009, compliance increased on unit A (from 65% to 91%) and unit B (from 74% to 92%). Improvement on each unit occurred only after the interventions were introduced. Identifying HCWs who failed to perform hand hygiene and offering alcohol-based hand rub to them before patient contact resulted in the greatest improvement. Improvements were sustained on both units for 18 months. CONCLUSIONS: Use of QI methods to implement a multimodal intervention resulted in sustained improvement in hand-hygiene compliance. Real-time individual performance feedback or other high-reliability human-factor interventions seem to be necessary to reach and sustain high levels of hand-hygiene compliance.
Assuntos
Desinfecção das Mãos/normas , Higiene/normas , Melhoria de Qualidade , Pessoal Técnico de Saúde , Humanos , Liderança , PediatriaRESUMO
PURPOSE: Doctors must understand patients' priorities to create an effective treatment partnership. Little is known about whether subspecialist pediatricians understand chronically ill adolescents' preferences. METHODS: A survey was conducted of 155 adolescents with chronic illnesses and 52 subspecialty physicians recruited from the same clinics of a children's hospital. Adolescents and physicians rated the importance that adolescents place on items relating to quality of care and physician-patient communication styles using a previously validated measure. RESULTS: For quality of care items, rank order correlation between physicians and patient responses was high (r = .63, p < .001) and both rated pain management items as most important. Physicians underestimated the importance adolescents placed on communicating with the physician as a friend and medical-technical aspects of care. For communication items, physicians' responses were significantly different than adolescents for 13 of 17 items. Except for three items pertaining to autonomy, physician and patient responses were in the same direction, but adolescent responses were less extreme. CONCLUSIONS: Physicians understood the importance of pain management to adolescents with chronic illnesses, but overestimated their desired level of autonomy. Asking adolescents for their preferences may be the first step in improving adolescents' experience of care.
Assuntos
Serviços de Saúde do Adolescente/estatística & dados numéricos , Manejo da Dor , Relações Médico-Paciente , Qualidade da Assistência à Saúde/estatística & dados numéricos , Adolescente , Comportamento do Adolescente/psicologia , Serviços de Saúde do Adolescente/organização & administração , Adulto , Anemia Falciforme/complicações , Artrite Juvenil/complicações , Criança , Doença Crônica , Fibrose Cística/complicações , Feminino , Necessidades e Demandas de Serviços de Saúde/estatística & dados numéricos , Humanos , Doenças Inflamatórias Intestinais/complicações , Masculino , Dor/etiologia , Dor/psicologia , Satisfação do Paciente , Vigilância da População , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: The goal was to test the hypothesis that participation in a community-based home-visiting program is associated with a decreased risk of infant death. METHODS: A retrospective, case-control design was used to compare the risk of infant death among participants in Cincinnati's Every Child Succeeds program and control subjects matched for gestational age at birth, previous pregnancy loss, marital status, and maternal age. The likelihood of infant death, adjusted for level of prenatal care, maternal smoking, maternal education, race, and age, was determined with multivariate logistic regression. The interaction between race and program participation and the effect of home visiting on the risk of preterm birth were explored. RESULTS: Infants whose families did not receive home visiting (n = 4995) were 2.5 times more likely to die in infancy compared with infants whose families received home visiting (n = 1665). Black infants were at least as likely to benefit from home visiting as were nonblack infants. No effect of program participation on the risk of preterm birth was observed. CONCLUSION: The current study is consistent with the hypothesis that intensive home visiting reduces the risk of infant death.
Assuntos
Visita Domiciliar/tendências , Mortalidade Infantil/tendências , Adolescente , Adulto , Estudos de Casos e Controles , Feminino , Humanos , Lactente , Recém-Nascido , Gravidez , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
OBJECTIVE: To determine the prevalence and identify variables associated with renal dysfunction in long-term survivors of pediatric liver transplantation. STUDY DESIGN: Data from 117 patients who survived>or=3 years after liver transplantation were analyzed. Demographic and clinical information was obtained from chart review and from a clinical care database. The dependent variable was renal function as determined by measured glomerular filtration rate (mGFR). Univariate and multivariate analyses were performed to identify independent variables associated with renal dysfunction (mGFR<70 mL/min per 1.73 m2). RESULTS: The average time since liver transplant was 7.6+/-3.4 years (range, 3 to 14.6 years). When the last available mGFR for all patients was analyzed, renal dysfunction was present in 32%. In the univariate analysis, mGFR at 1 year after transplant, cyclosporine immunosuppression, and time since transplant were significant; the second two were strongly collinear. Using multiple logistic regression modeling excluding time since transplant, cyclosporine and mGFR at 1 year after transplant were strongly associated with renal dysfunction. CONCLUSIONS: Renal dysfunction is a common complication in children who survive liver transplantation. Our observations are of critical importance because children may live long enough to move from a stage of renal insufficiency characterized by asymptomatic decreased GFR to symptomatic end-stage renal disease.
Assuntos
Transplante de Fígado , Complicações Pós-Operatórias/epidemiologia , Insuficiência Renal Crônica/epidemiologia , Adolescente , Adulto , Estudos de Casos e Controles , Criança , Pré-Escolar , Ciclosporina/efeitos adversos , Feminino , Taxa de Filtração Glomerular , Humanos , Terapia de Imunossupressão/efeitos adversos , Imunossupressores/efeitos adversos , Lactente , Recém-Nascido , Falência Renal Crônica/epidemiologia , Modelos Logísticos , Masculino , Análise Multivariada , Ohio/epidemiologia , Complicações Pós-Operatórias/diagnóstico , Prevalência , Insuficiência Renal Crônica/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Sobreviventes/estatística & dados numéricos , Fatores de TempoRESUMO
OBJECTIVE: Scant information exists on the effects of legislation mandating coverage of minimum postnatal hospital stays on infant health outcomes. There are also gaps in knowledge regarding the effectiveness of early follow-up visits for newborns. The objective of this study was to determine the impact of 1) legislation mandating coverage of minimum postnatal hospital stays and 2) early follow-up visits by the age of 4 days on infant outcomes during the first month of life. METHODS: A retrospective analysis was conducted of Ohio Medicaid claims data linked with birth certificate data for the period 1991-1998. The impact of the legislation was evaluated using interrupted time-series analysis of health-related utilization. The effects of early follow-up visits for vaginally delivered newborns with short stays were analyzed using the day of the week on which the birth occurred (eg, Monday, Tuesday) as an instrumental variable to account for potential confounding. A total of 155,352 full-term newborns who were born to mothers who receive Medicaid were studied. The main outcomes measured were rehospitalizations, emergency department (ED) visits, and diagnoses of dehydration and infection within 10 and 21 days of birth. RESULTS: Few outcomes exhibited significant changes after legislation mandating coverage of minimum postnatal hospital stays. Rates of rehospitalization for jaundice within 10 days of birth fell from 0.78% to 0.47% in the year after legislation was introduced but leveled off after the legislation took effect. Rates of ED visits within 21 days increased from 6.0% to 10.4% during periods of increasing short stay but fell to 8.0% during the year after introduction of the legislation and leveled off when the legislation took effect. Rates of all-cause rehospitalization, dehydration, and infection diagnoses showed no consistent relationship to Ohio's legislation. Using instrumental variable analysis, newborns who received early follow-up visits were significantly less likely to have rehospitalizations within the first 10 days of life than those who did not. CONCLUSIONS: In this state Medicaid population, legislation mandating coverage of minimum postnatal hospital stays was associated with reductions in the rates of rehospitalization for jaundice and ED visits. For newborns with short stays, early follow-up visits may reduce rehospitalizations in the early postpartum period.
Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Icterícia Neonatal/epidemiologia , Tempo de Internação/legislação & jurisprudência , Readmissão do Paciente/estatística & dados numéricos , Desidratação/epidemiologia , Humanos , Recém-Nascido , Infecções/epidemiologia , Modelos Lineares , Medicaid , Ohio , Alta do Paciente/legislação & jurisprudência , Estudos RetrospectivosRESUMO
OBJECTIVES: To determine the characteristics of nonurgent emergency department (ED) visits in the first 3 months of life. METHODS: The study cohort consisted of full-term newborns admitted to and discharged from one newborn nursery from September 1, 1992, to May 1, 1994. All visits in the first 90 days of life to one large urban ED were analyzed to determine whether they were nonurgent, based on history of present illness and final diagnosis or disposition. The principal outcomes of interest were the frequency and pattern of nonurgent ED visits. Risk factors for nonurgent ED use were also studied. RESULTS: A total of 2137 patients with 965 ED visits were analyzed; 20.4% of the patients had nonurgent visits, and 60.1% of all visits were nonurgent. Of all patients with nonurgent visits, 24.1% had more than one. Younger maternal age, Medicaid, maternal parity, and nonwhite race all resulted in increased nonurgent ED use. One third of all ED visits were made when the primary care physician's offices were open, and 57.6% of these visits were nonurgent. CONCLUSIONS: Maternal and economic factors affected nonurgent ED utilization. Other critical factors still need to be explored. Interventions focused on decreasing nonurgent ED use in early infancy should be targeted at patients with the identified risk factors.
Assuntos
Serviços de Saúde da Criança/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Mau Uso de Serviços de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/estatística & dados numéricos , Adulto , Estudos de Coortes , Feminino , Humanos , Lactente , Recém-Nascido , Mães/estatística & dados numéricos , Ohio , Paridade , Fatores de RiscoRESUMO
OBJECTIVES: To examine the impact of state legislation mandating minimum maternal and newborn length of stay (LOS). STUDY DESIGN: By using Medicaid claims data linked to vital statistics files, LOS, and "short stay" (=1 day after vaginal delivery, =2 days after cesarean delivery) were determined for 151,464 term newborns born to mothers receiving Medicaid in Ohio from July 1, 1991 to June 30, 1998. Changes in LOS and "short stay" were examined for 4 periods that reflected events occurring in Ohio at the time. RESULTS: The proportion of newborns discharged after a "short stay" increased dramatically before legislation (7/1/91-8/31/95) but decreased after the introduction of legislation (9/1/95-6/30/96). In the 4 months after passage of the law, but before its effective date (Period III), the odds of a "short stay" decreased. This decrease continued in the 20 months after the law went into effect (Period IV). White, young, married mothers without a high school degree or with poor prenatal care and lower birth weight infants were more likely to be discharged early. CONCLUSIONS: LOS and "short stay" returned to near-1991 levels for Medicaid newborns in Ohio after legislative activity.
Assuntos
Tempo de Internação/legislação & jurisprudência , Medicaid/legislação & jurisprudência , Assistência Perinatal/legislação & jurisprudência , Parto Obstétrico/métodos , Humanos , Recém-Nascido , Tempo de Internação/economia , Modelos Logísticos , Berçários Hospitalares , Razão de Chances , Ohio , Assistência Perinatal/economia , Estudos Retrospectivos , Governo Estadual , Estados UnidosRESUMO
BACKGROUND: In our cost- and radiation-conscious environment, the feasibility of performing only a frontal radiograph for the diagnosis of pneumonia in children needs to be reassessed. OBJECTIVE: To determine the diagnostic efficacy of the frontal radiograph alone in comparison to the frontal and lateral combined radiographs for the radiographic diagnosis of pneumonia in children. MATERIALS AND METHODS: Three radiologists retrospectively and independently reviewed the frontal radiographs alone and separately reviewed the frontal and lateral radiographs of 1,268 children referred from the emergency room for chest radiographs. A majority interpretation of at least two radiologists for the frontal views alone was compared with majority interpretation of the frontal and lateral combined views for the radiographic diagnosis of pneumonia. "Pneumonia" was defined as a focus of streaky or confluent lung opacity. RESULTS: For the radiographic diagnosis of pneumonia, the sensitivity and specificity of the frontal view alone were 85% and 98%, respectively. For the confluent lobar type of pneumonia, the sensitivity and specificity increased to 100%. CONCLUSION: When the frontal view alone yields a diagnosis of confluent lobar pneumonia, this is highly reliable. However, nonlobar types of infiltrates will be underdiagnosed in 15% of patients using the frontal view alone. The clinical impact of these radiographically underdiagnosed pneumonias needs to be assessed prior to implementing the practice of using only frontal radiographs for diagnosing pneumonia.
Assuntos
Pneumonia Pneumocócica/diagnóstico por imagem , Radiografia Torácica/métodos , Adolescente , Distribuição de Qui-Quadrado , Criança , Pré-Escolar , Diagnóstico Diferencial , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Efforts to make health care for adolescents with chronic illnesses more patient-centered must be grounded in an understanding and clear measures of adolescents' preferences and priorities. OBJECTIVE: To develop a measure of health care preferences of adolescents with chronic illnesses and to determine demographic, developmental, and health factors associated with adolescents' preferences. DESIGN: Mixed-method questionnaire development and survey. SETTING: Subspecialty clinics of a tertiary care children's hospital. PARTICIPANTS: All adolescents (age: 11-19 years) with juvenile rheumatoid arthritis, sickle cell disease, inflammatory bowel disease, or cystic fibrosis of at least 2-year duration who were being treated at the participating center were eligible to participate, and 155 of 251 did so (62%). The participants had a mean age of 15.5 +/- 2.4 years, 45% were male, and 75% were white. INTERVENTION: None. MAIN OUTCOME MEASURES: Ratings of 65 items related to quality of care and 17 items related to physician-patient communication styles. RESULTS: An 82-item questionnaire, devised from qualitative analysis of focus group results, contained 65 Likert scale items that adolescents considered important for health care quality and 17 forced-choice items related to adolescents' preferences for communication. Among the first 65 items, the group of questions related to physician trust and respect had the highest rating of 5.24 +/- 0.62 of 6, followed by patient power and control (mean rating: 4.72 +/- 0.77) and then caring and closeness in the patient-doctor relationship (mean rating: 4.19 +/- 0.91). For the communication items, the adolescents, on average, preferred communication directly to them rather than to their parents and were nearly neutral regarding physicians' inquiries about personal issues. CONCLUSIONS: Participants rated aspects of interpersonal care (especially honesty, attention to pain, and items related to respect) as most important in their judgments of quality. As in most previous studies of adults, technical aspects of care were also rated highly, suggesting that adolescents understand and value both scientific and interpersonal aspects of care.
Assuntos
Atitude Frente a Saúde , Doença Crônica/terapia , Atenção à Saúde , Adolescente , Serviços de Saúde do Adolescente , Adulto , Anemia Falciforme/terapia , Artrite Juvenil/terapia , Criança , Fibrose Cística/terapia , Coleta de Dados , Feminino , Pesquisa sobre Serviços de Saúde , Humanos , Doenças Inflamatórias Intestinais/terapia , Masculino , Análise Multivariada , Relações Médico-Paciente , Qualidade da Assistência à Saúde , Assunção de Riscos , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To describe the effect of evidence-based point-of-care algorithms and rules, based on guideline recommendations, on the overuse of therapies for bronchiolitis. Study design Pre-postintervention for infants <1 year of age admitted with a first-time episode of bronchiolitis. Data collected for guideline-eligible patients discharged between January 15, 2002, and March 27, 2002, were compared with data collected for guideline-eligible patients discharged from the hospital with a diagnosis of bronchiolitis during the same time period in the first 5 years after the original guideline implementation (1997 to 2001). The primary outcome of interest was use of bronchodilator therapy. Secondary outcomes included use of guideline order sets, resource utilization, length of stay, and readmission. RESULTS: A total of 256 patients from 2002 were compared with 1272 historic patients. In 2002, the odds of receiving any bronchodilator, more than 1, more than 2, and more than 4 bronchodilators were all significantly less than predicted by the 1997 to 2001 year-to-year trend. The odds of receiving a nasopharyngeal wash for respiratory syncytial virus and a chest radiography (OR=0.680, CL=0.476, 0.973) were also significantly lower than what was predicted from use trends of previous years. CONCLUSIONS: Evidence-based point-of-care instruments can have a significant effect on unwarranted treatment variation.
Assuntos
Bronquiolite/terapia , Fidelidade a Diretrizes , Mau Uso de Serviços de Saúde , Pediatria/normas , Guias de Prática Clínica como Assunto , Algoritmos , Bronquiolite/tratamento farmacológico , Broncodilatadores/uso terapêutico , Medicina Baseada em Evidências , Recursos em Saúde/estatística & dados numéricos , Humanos , Lactente , Cuidado do Lactente/normas , Recém-Nascido , Modelos Lineares , Modelos Logísticos , Ohio , Avaliação de Processos e Resultados em Cuidados de SaúdeRESUMO
BACKGROUND: Guidelines for preventing and treating acute gastroenteritis (AGE) have generally not been incorporated into medical practice. An evidence-based clinical practice guideline was adapted from national guidelines to meet the practice styles characterizing care in southwestern Ohio and implemented at the Children's Hospital Medical Center (Cincinnati). Its efficacy was assessed in terms of emergency department (ED) encounters and admissions, mean and total hospital costs, and mean length of hospitalization. METHODS: Comparisons were made between patients seen during peak gastroenteritis months (December-May) before (fiscal year [FYs] 1994-1997) and after (FYs 1998 and 1999) guideline implementation. Data were extracted from hospital charts, clinical databases, and billing records. RESULTS: Following implementation, mean yearly ED encounters for AGE decreased 22% and mean yearly admissions decreased 33%. The percentage of admitted children with minor illness decreased (p = 0.002). Mean length of stay decreased 21% for children with minor illness (p = 0.0001) and 5% for others. Hydration status was noted in only 15% of ED charts examined but increased to 63% in FY 1998 and 86% in FY 1999 (p < 0.001). The proportion of admitted patients who advanced to a regular diet by discharge increased from 4.9% (FY 1997) to 23% (FY 1998) and 76% (FY 1999; p < 0.0001). Total inpatient days/year decreased by 43%. Mean hospital costs did not change significantly. DISCUSSION: Following implementation, fewer patients with AGE were seen in the ED and fewer were admitted to the hospital for care. Hospital stays were shorter, and children were more likely to resume their diets before discharge.
Assuntos
Diarreia Infantil/terapia , Medicina Baseada em Evidências , Hidratação/normas , Gastroenterite/terapia , Fidelidade a Diretrizes , Hospitais Pediátricos/normas , Guias de Prática Clínica como Assunto , Doença Aguda , Pré-Escolar , Desidratação/etiologia , Desidratação/prevenção & controle , Diarreia Infantil/complicações , Diarreia Infantil/economia , Diarreia Infantil/etiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Gastroenterite/complicações , Gastroenterite/economia , Hospitais Pediátricos/economia , Hospitais Pediátricos/estatística & dados numéricos , Humanos , Lactente , Tempo de Internação/estatística & dados numéricos , Ohio , Admissão do Paciente/estatística & dados numéricos , Sociedades MédicasRESUMO
Our primary goal was to assess health related quality of life (HRQOL) at transplantation and 1 yr after transplantation in pediatric liver transplant patients aged less than 5 years. We conducted a prospective longitudinal study of HRQOL in pediatric liver transplant recipients, aged less than 5 years to define the impact of liver transplantation on HRQOL and identify factors that predict HRQOL after transplantation. The infant toddler health status questionnaire (ITHQ) was completed at the time of listing for liver transplantation and at 6 and 12 months after liver transplantation. The primary outcome measures were the subscale scores that comprise ITHQ. The mean age (+/-s.e.m.) of the enrolled patients (n = 45) at transplantation was 1.4 (+/-1.2) yr. Thirty-eight (84%) of the enrolled patients completed the study. The highest mean baseline scores of 78.6 (+/-3.3) were for global mental health (GlobalMH). ITHQ subscale scores increased steadily after transplantation. The greatest increase was in the first 6 months after transplant. At 1 yr after transplantation, there were significant increases in all of the ITHQ subscale scores except for GlobalMH. ITHQ subscales were similar for patients who received LDLT compared with those who received cadaver donor liver transplantation (CDLT) at baseline and a year after transplant. Time elapsed as transplantation was a significant predictor of functional health in all of the models generated. Scores for general health (GH), global health (GGH), parental time-impact (PT) and parental time-emotion (PE) were higher for male children. Family cohesion (FC) improved with time elapsed since transplant and increased number of inpatient days. HRQOL improves after transplantation in all of our patients irrespective of the donor type. Functional health scores were higher in patients with normal serum bilirubin at 1 yr post-transplant. Assessment of HRQOL should be an integral part of care for liver transplant patients and their caregivers.
Assuntos
Nível de Saúde , Transplante de Fígado , Qualidade de Vida , Bilirrubina/sangue , Cadáver , Emoções , Feminino , Humanos , Lactente , Comportamento do Lactente , Doadores Vivos , Estudos Longitudinais , Masculino , Pais/psicologia , Inquéritos e QuestionáriosRESUMO
The goals of the present study were (1) to measure health-related quality of life (HRQOL) in pediatric liver transplantation (LT), (2) to identify demographic and clinical factors that correlate with HRQOL, and (3) to compare two instruments that have been used to measure HRQOL in children and adolescents. We conducted a single-center cross-sectional study of 77 pediatric LT recipients ages 5 to 18 years, all of whom had had LT at least 6 months previously. We used the Child Health Questionnaire Parent Form 50 (CHQPF50) and the PedsQL4.0 to determine measured dimensions of physical and psychosocial health from the parents' perspective. Individual scale scores range from 0 to 100, with higher scores reflecting better health. Data on demographics, clinical status at transplantation, posttransplantation clinical course, and graft function were collected to identify predictors of posttransplantation HRQOL. Fifty-three percent of the liver transplant recipients had biliary atresia, 78% were white, and 61% were female. The mean age at LT was 3.8 +/- 3.6 years, and the range of time since LT was 1 to 15 years. HRQOL in pediatric liver transplant recipients was lower than that reported for healthy children but similar to that for children with other chronic illness. Age at transplantation, the time elapsed since transplantation, hospitalizations within the previous year, maternal education, and race were significant predictors of physical health. Age at transplantation and maternal education predicted psychosocial function. HRQOL was decreased in a population of pediatric liver transplant recipients compared with the general population and similar to that for children with chronic illness. Prospective longitudinal studies will permit us to define predictors of HRQOL at different periods of time after transplantation. The information gained from this study will help us to better define expectations and the clinical course after liver transplantation to patients and their families.