Photoacoustic imaging of squirrel monkey cortical responses induced by peripheral mechanical stimulation.

Non-human primates (NHPs) are crucial models for studies of neuronal activity. Emerging photoacoustic imaging modalities offer excellent tools for studying NHP brains with high sensitivity and high spatial resolution. In this research, a photoacoustic microscopy (PAM) device was used to provide a label-free quantitative characterization of cerebral hemodynamic changes due to peripheral mechanical stimulation. A 5 × 5 mm area within the somatosensory cortex region of an adult squirrel monkey was imaged. A deep, fully connected neural network was characterized and applied to the PAM images of the cortex to enhance the vessel structures after mechanical stimulation on the forelimb digits. The quality of the PAM images was improved significantly with a neural network while preserving the hemodynamic responses. The functional responses to the mechanical stimulation were characterized based on the improved PAM images. This study demonstrates capability of PAM combined with machine learning for functional imaging of the NHP brain.

Annual Prevalence of Opioid Receipt by South Carolina Medicaid-Enrolled Children and Adolescents: 2000-2020.

Understanding patterns of opioid receipt by children and adolescents over time and understanding differences between age groups can help identify opportunities for future opioid stewardship. We conducted a retrospective cohort study, using South Carolina Medicaid data for children and adolescents 0-18 years old between 2000-2020, calculating the annual prevalence of opioid receipt for medical diagnoses in ambulatory settings. We examined differences in prevalence by calendar year, race/ethnicity, and by age group. The annual prevalence of opioid receipt for medical diagnoses changed significantly over the years studied, from 187.5 per 1000 in 2000 to 41.9 per 1000 in 2020 (Cochran-Armitage test for trend, p < 0.0001). In all calendar years, older ages were associated with greater prevalence of opioid receipt. Adjusted analyses (logistic regression) assessed calendar year differences in opioid receipt, controlling for age group, sex, and race/ethnicity. In the adjusted analyses, calendar year was inversely associated with opioid receipt (aOR 0.927, 95% CI 0.926-0.927). Males and older ages were more likely to receive opioids, while persons of Black race and Hispanic ethnicity had lower odds of receiving opioids. While opioid receipt declined among all age groups during 2000-2020, adolescents 12-18 had persistently higher annual prevalence of opioid receipt when compared to younger age groups.

Stimulation-Evoked Effective Connectivity (SEEC): An in-vivo approach for defining mesoscale corticocortical connectivity.

BACKGROUND: Cortical electrical stimulation is a versatile technique for examining the structure and function of cortical regions and for implementing novel therapies. While electrical stimulation has been used to examine the local spread of neural activity, it may also enable longitudinal examination of mesoscale interregional connectivity. NEW METHOD: Here, we sought to use intracortical microstimulation (ICMS) in conjunction with recordings of multi-unit action potentials to assess the mesoscale effective connectivity within sensorimotor cortex. Neural recordings were made from multielectrode arrays placed into sensory, motor, and premotor regions during surgical experiments in three squirrel monkeys. During each recording, single-pulse ICMS was repeatably delivered to a single region. Mesoscale effective connectivity was calculated from ICMS-evoked changes in multi-unit firing. RESULTS: Multi-unit action potentials were able to be detected on the order of 1 ms after each ICMS pulse. Across sensorimotor regions, short-latency (< 2.5 ms) ICMS-evoked neural activity strongly correlated with known anatomical connections. Additionally, ICMS-evoked responses remained stable across the experimental period, despite small changes in electrode locations and anesthetic state. COMPARISON WITH EXISTING METHODS: Previous imaging studies investigating cross-regional responses to stimulation are limited to utilizing indirect hemodynamic responses and thus lack the temporal specificity of ICMS-evoked responses. CONCLUSIONS: These results show that monitoring ICMS-evoked neural activity, in a technique we refer to as Stimulation-Evoked Effective Connectivity (SEEC), is a viable way to longitudinally assess effective connectivity, enabling studies comparing the time course of connectivity changes with the time course of changes in behavioral function.

Deimplementation of Polycythemia Screening in Asymptomatic Infants in a Level 1 Nursery.

Polycythemia (venous hematocrit >65%) is rare in healthy newborns (incidence: 0.4%-5%), with serious outcomes (stroke, bowel ischemia) of unknown incidence in asymptomatic infants. No national guidelines address screening or management of asymptomatic infants with polycythemia. Our nursery screened "high risk" (HR) newborns (small for gestational age, large for gestational age, twin, infant of diabetic mother) with poor adherence and low yield. We aimed to decrease polycythemia screening of asymptomatic HR infants by 80% within 6 months. Methods: We conducted an improvement project at a tertiary children's hospital using the Model for Improvement. Eligible infants had an HR ICD-10 code on their problem list, were asymptomatic, over 35 weeks gestational age, and remained in the nursery for >6 hrs. Interventions included discontinuation of prior protocol, education for staff, bimonthly feedback on project performance, and visual reminders. Our primary outcome measure was the proportion of asymptomatic infants who received a hematocrit screen. Secondary measures were screening costs. Balancing measures were the length of stay, detected/symptomatic polycythemia, transfers to ICU/wards, and readmissions within 1 week of discharge. Results: The Nursery unit screened 80% of HR infants at baseline. This decreased to 7.3% after PDSA1, 0% after PDSA2, and 1% after PDSA3. There was no symptomatic polycythemia or statistically significant increase in readmissions/transfers. One month of monitoring revealed persistent changes. Conclusion: Simple quality improvement interventions such as education, reminders, and feedback can facilitate the deimplementation of low-value practices.

Pediatric surgical site infection (SSI) following ambulatory surgery: Incidence, risk factors and patient outcomes.

BACKGROUND: Inpatient surgical site infections (SSIs) cause morbidity in children. The SSI rate among pediatric ambulatory surgery patients is less clear. To fill this gap, we conducted a multiple-institution, retrospective epidemiologic study to identify incidence, risk factors, and outcomes. METHODS: We identified patients aged <22 years with ambulatory visits between October 2010 and September 2015 via electronic queries at 3 medical centers. We performed sample chart reviews to confirm ambulatory surgery and adjudicate SSIs. Weighted Poisson incidence rates were calculated. Separately, we used case-control methodology using multivariate backward logistical regression to assess risk-factor association with SSI. RESULTS: In total, 65,056 patients were identified by queries, and we performed complete chart reviews for 13,795 patients; we identified 45 SSIs following ambulatory surgery. The weighted SSI incidence following pediatric ambulatory surgery was 2.00 SSI per 1,000 ambulatory surgeries (95% confidence interval [CI], 1.37-3.00). Integumentary surgeries had the highest weighted SSI incidence, 3.24 per 1,000 ambulatory surgeries (95% CI, 0.32-12). The following variables carried significantly increased odds of infection: clean contaminated or contaminated wound class compared to clean (odds ratio [OR], 9.8; 95% CI, 2.0-48), other insurance type compared to private (OR, 4.0; 95% CI, 1.6-9.8), and surgery on weekend day compared to weekday (OR, 30; 95% CI, 2.9-315). Of the 45 instances of SSI following pediatric ambulatory surgery, 40% of patients were admitted to the hospital and 36% required a new operative procedure or bedside incision and drainage. CONCLUSIONS: Our findings suggest that morbidity is associated with SSI following ambulatory surgery in children, and we also identified possible targets for intervention.

Pediatrician Adherence to Guidelines for Diagnosis and Management of High Blood Pressure.

OBJECTIVES: To assess pediatrician adherence to the 2017 American Academy of Pediatrics' clinical practice guideline for high blood pressure (BP). STUDY DESIGN: Pediatric primary care practices (n = 59) participating in a quality improvement collaborative submitted data for patients with high BP measured between November 2018 and January 2019. Baseline data included patient demographics, BP, body mass index (BMI), and actions taken. Logistic regression was used to test associations between patient BP level and BMI with provider adherence to guidelines (BP measurement, counseling, follow-up, evaluation). RESULTS: A total of 2677 patient charts were entered for analysis. Only 2% of patients had all BP measurement steps completed correctly, with fewer undergoing 3-limb and ambulatory BP measurement. Overall, 46% of patients received appropriate weight, nutrition, and lifestyle counseling. Follow-up for high BP was recommended or scheduled in 10% of encounters, and scheduled at the appropriate interval in 5%. For patients presenting with their third high BP measurement, 10% had an appropriate diagnosis documented, 2% had appropriate screening laboratory tests conducted, and none had a renal ultrasound performed. BMI was independently associated with increased odds of counseling, but higher BP was associated with lower odds of counseling. Higher BP was independently associated with an increased likelihood of documentation of hypertension. CONCLUSIONS: In this multisite study, adherence to the 2017 American Academy of Pediatrics' guideline for high BP was low. Given the long-term health implications of high BP in childhood, it is important to improve primary care provider recognition and management. TRIAL REGISTRATION: ClinicalTrials.gov: NCT03783650.

Preventing Home Medication Administration Errors.

Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.

Central Venous Catheter Salvage in Ambulatory Central Line-Associated Bloodstream Infections.

BACKGROUND: Guidelines for treatment of central line-associated bloodstream infection (CLABSI) recommend removing central venous catheters (CVCs) in many cases. Clinicians must balance these recommendations with the difficulty of obtaining alternate access and subjecting patients to additional procedures. In this study, we evaluated CVC salvage in pediatric patients with ambulatory CLABSI and associated risk factors for treatment failure. METHODS: This study was a secondary analysis of 466 ambulatory CLABSIs in patients <22 years old who presented to 5 pediatric medical centers from 2010 to 2015. We defined attempted CVC salvage as a CVC left in place ≥3 days after a positive blood culture result. Salvage failure was removal of the CVC ≥3 days after CLABSI. Successful salvage was treatment of CLABSI without removal of the CVC. Bivariate and multivariable logistic regression analyses were used to test associations between risk factors and attempted and successful salvage. RESULTS: A total of 460 ambulatory CLABSIs were included in our analysis. CVC salvage was attempted in 379 (82.3%) cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with attempted salvage. Salvage was successful in 287 (75.7%) attempted cases. Underlying diagnosis, CVC type, number of lumens, and absence of candidemia were associated with successful salvage. In patients with malignancy, neutropenia within 30 days before CLABSI was significantly associated with both attempted salvage and successful salvage. CONCLUSIONS: CVC salvage was often attempted and was frequently successful in ambulatory pediatric patients presenting with CLABSI.

A cortical injury model in a non-human primate to assess execution of reach and grasp actions: implications for recovery after traumatic brain injury.

BACKGROUND: Technological advances in developing experimentally controlled models of traumatic brain injury (TBI) are prevalent in rodent models and these models have proven invaluable in characterizing temporal changes in brain and behavior after trauma. To date no long-term studies in non-human primates (NHPs) have been published using an experimentally controlled impact device to follow behavioral performance over time. NEW METHOD: We have employed a controlled cortical impact (CCI) device to create a focal contusion to the hand area in primary motor cortex (M1) of three New World monkeys to characterize changes in reach and grasp function assessed for 3 months after the injury. RESULTS: The CCI destroyed most of M1 hand representation reducing grey matter by 9.6 mm3, 12.9 mm3, and 15.5 mm3 and underlying corona radiata by 7.4 mm3, 6.9 mm3, and 5.6 mm3 respectively. Impaired motor function was confined to the hand contralateral to the injury. Gross hand-use was only mildly affected during the first few days of observation after injury while activity requiring skilled use of the hand was impaired over three months. COMPARISON WITH EXISTING METHOD(S): This study is unique in establishing a CCI model of TBI in an NHP resulting in persistent impairments in motor function evident in volitional use of the hand. CONCLUSIONS: Establishing an NHP model of TBI is essential to extend current rodent models to the complex neural architecture of the primate brain. Moving forward this model can be used to investigate novel therapeutic interventions to improve or restore impaired motor function after trauma.

Pediatric Ambulatory Central Line-Associated Bloodstream Infections.

BACKGROUND: Inpatient pediatric central line-associated bloodstream infections (CLABSIs) cause morbidity and increased health care use. Minimal information exists for ambulatory CLABSIs despite ambulatory central line (CL) use in children. In this study, we identified ambulatory pediatric CLABSI incidence density, risk factors, and outcomes. METHODS: Retrospective cohort with nested case-control study at 5 sites from 2010 through 2015. Electronic queries were used to identify potential cases on the basis of administrative and laboratory data. Chart review was used to confirm ambulatory CL use and adjudicated CLABSIs. Bivariate followed by multivariable backward logistic regression was used to identify ambulatory CLABSI risk factors. RESULTS: Queries identified 4600 potentially at-risk children; 1658 (36%) had ambulatory CLs. In total, 247 (15%) patients experienced 466 ambulatory CLABSIs with an incidence density of 0.97 CLABSIs per 1000 CL days. Incidence density was highest among patients with tunneled externalized catheters versus peripherally inserted central catheters and totally implanted devices: 2.58 CLABSIs per 1000 CL days versus 1.46 vs 0.23, respectively (P < .001). In a multivariable model, clinic visit (odds ratio [OR] 2.8; 95% confidence interval [CI]: 1.4-5.5) and low albumin (OR 2.3; 95% CI: 1.2-4.3) were positively associated with CLABSI, and prophylactic antimicrobial agents for underlying conditions within the preceding 30 days (OR 0.22; 95% CI: 0.12-0.40) and operating room CL placement (OR 0.36; 95% CI: 0.16-0.79) were inversely associated with CLABSI. A total of 396 patients (85%) were hospitalized because of ambulatory CLABSI with an 8-day median length of stay (interquartile range 5-13). CONCLUSIONS: Ambulatory pediatric CLABSI incidence density is appreciable and associated with health care use. CL type, patients with low albumin, prophylactic antimicrobial agents, and placement setting may be targets for reduction efforts.

Effects of tDCS on spontaneous spike activity in a healthy ambulatory rat model.

BACKGROUND: The neurophysiological effects of transcranial direct current stimulation (tDCS) are typically described with respect to changes in cortical excitability, defined by using transcranial magnetic stimulation pulses to determine changes in motor evoked potentials. However, how individual cortical neurons change firing patterns under the influence of tDCS is largely unknown. While the relatively weak currents produced in the brain by tDCS may not be adequate to directly depolarize neuronal membranes, ongoing neuronal activity, combined with subthreshold changes in membrane polarization might be sufficient to alter the threshold for neural firing. OBJECTIVES: The purpose of this study was to determine the effects of tDCS on neurophysiological activity in motor cortex of freely moving, healthy rats. METHODS: In nine healthy, ambulatory rats, each studied under six different stimulation conditions varying in current intensity (maximum current density = 39.8 A/m2 at 0.4 mA) and polarity (anodal or cathodal), neural activity was analyzed in response to 20 min of tDCS applied through bone screws insulated from the overlying scalp. RESULTS: After analysis of 480 multi-unit channels that satisfied a rigid set of neurophysiological criteria, we found no systematic effect of tDCS stimulation condition on firing rate or firing pattern. Restricting the analysis to the most responsive units, subtle, but statistically significant changes occurred only in the highest intensity anodal condition. CONCLUSIONS: These results confirm that at current densities typically used in human or animal tDCS studies, observed effects of tDCS are likely to occur via mechanisms other than direct neuronal depolarization.

Costs of ambulatory pediatric healthcare-associated infections: Central-line-associated bloodstream infection (CLABSIs), catheter-associated urinary tract infection (CAUTIs), and surgical site infections (SSIs).

OBJECTIVE: Ambulatory healthcare-associated infections (HAIs) occur frequently in children and are associated with morbidity. Less is known about ambulatory HAI costs. This study estimated additional costs associated with pediatric ambulatory central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTI), and surgical site infections (SSIs) following ambulatory surgery. DESIGN: Retrospective case-control study. SETTING: Four academic medical centers. PATIENTS: Children aged 0-22 years seen between 2010 and 2015 and at risk for HAI as identified by electronic queries. METHODS: Chart review adjudicated HAIs. Charges were obtained for patients with HAIs and matched controls 30 days before HAI, on the day of, and 30 days after HAI. Charges were converted to costs and 2015 USD. Mixed-effects linear regression was used to estimate the difference-in-differences of HAI case versus control costs in 2 models: unrecorded charge values considered missing and a sensitivity analysis with unrecorded charge considered $0. RESULTS: Our search identified 177 patients with ambulatory CLABSIs, 53 with ambulatory CAUTIs, and 26 with SSIs following ambulatory surgery who were matched with 382, 110, and 75 controls, respectively. Additional cost associated with an ambulatory CLABSI was $5,684 (95% confidence interval [CI], $1,005-$10,362) and $6,502 (95% CI, $2,261-$10,744) in the 2 models; cost associated with a CAUTI was $6,660 (95% CI, $1,055, $12,145) and $2,661 (95% CI, -$431 to $5,753); cost associated with an SSI following ambulatory surgery at 1 institution only was $6,370 (95% CI, $4,022-$8,719). CONCLUSIONS: Ambulatory HAI in pediatric patients are associated with significant additional costs. Further work is needed to reduce ambulatory HAIs.

Contributing Factors for Pediatric Ambulatory Diagnostic Process Errors: Project RedDE.

BACKGROUND: Pediatric ambulatory diagnostic errors (DEs) occur frequently. We used root cause analyses (RCAs) to identify their failure points and contributing factors. METHODS: Thirty-one practices were enrolled in a national QI collaborative to reduce 3 DEs occurring at different stages of the diagnostic process: missed adolescent depression, missed elevated blood pressure (BP), and missed actionable laboratory values. Practices were encouraged to perform monthly "mini-RCAs" to identify failure points and prioritize interventions. Information related to process steps involved, specific contributing factors, and recommended interventions were reported monthly. Data were analyzed using descriptive statistics and Pareto charts. RESULTS: Twenty-eight (90%) practices submitted 184 mini-RCAs. The median number of mini-RCAs submitted was 6 (interquartile range, 2-9). For missed adolescent depression, the process step most commonly identified was the failure to screen (68%). For missed elevated BP, it was the failure to recognize (36%) and act on (28%) abnormal BP. For missed actionable laboratories, failure to notify families (23%) and document actions on (19%) abnormal results were the process steps most commonly identified. Top contributing factors to missed adolescent depression included patient volume (16%) and inadequate staffing (13%). Top contributing factors to missed elevated BP included patient volume (12%), clinic milieu (9%), and electronic health records (EHRs) (8%). Top contributing factors to missed actionable laboratories included written communication (13%), EHR (9%), and provider knowledge (8%). Recommended interventions were similar across errors. CONCLUSIONS: EHR-based interventions, standardization of processes, and cross-training may help decrease DEs in the pediatric ambulatory setting. Mini-RCAs are useful tools to identify their contributing factors and interventions.

Pediatric ambulatory catheter-associated urinary tract infections (CAUTIs): Incidence, risk factors, and patient outcomes.

OBJECTIVE: Catheter-associated urinary tract infections (CAUTIs) occur frequently in pediatric inpatients, and they are associated with increased morbidity and cost. Few studies have investigated ambulatory CAUTIs, despite at-risk children utilizing home urinary catheterization. This retrospective cohort and case-control study determined incidence, risk factors, and outcomes of pediatric patients with ambulatory CAUTI. DESIGN: Broad electronic queries identified potential patients with ambulatory urinary catheters, and direct chart review confirmed catheters and adjudicated whether ambulatory CAUTI occurred. CAUTI definitions included clean intermittent catheterization (CIC). Our matched case-control analysis assessed risk factors. SETTING: Five urban, academic medical centers, part of the New York City Clinical Data Research Network. PATIENTS: Potential patients were age <22 years who were seen between October 2010 and September 2015. RESULTS: In total, 3,598 eligible patients were identified; 359 of these used ambulatory catheterization (representing186,616 ambulatory catheter days). Of these, 63 patients (18%) experienced 95 ambulatory CAUTIs. The overall ambulatory CAUTI incidence was 0.51 infections per 1,000 catheter days (1.35 for indwelling catheters and 0.47 for CIC; incidence rate ratio, 2.88). Patients with nonprivate medical insurance (odds ratio, 2.5; 95% confidence interval, 1.1-6.3) were significantly more likely to have ambulatory CAUTIs in bivariate models but not multivariable models. Also, 45% of ambulatory CAUTI resulted in hospitalization (median duration, 3 days); 5% resulted in intensive care admission; 47% underwent imaging; and 88% were treated with antibiotics. CONCLUSIONS: Pediatric ambulatory CAUTIs occur in 18% of patients with catheters; they are associated with morbidity and healthcare utilization. Ambulatory indwelling catheter CAUTI incidence exceeded national inpatient incidence. Future quality improvement research to reduce these harmful infections is warranted.

Mucosal barrier injury-associated bloodstream infections in pediatric oncology patients.

BACKGROUND: Single-center reports of central line-associated bloodstream infection (CLABSI) and the subcategory of mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) in pediatric hematology oncology transplant (PHO) patients have focused on the inpatient setting. Characterization of MBI-LCBI across PHO centers and management settings (inpatient and ambulatory) is urgently needed to inform surveillance and prevention strategies. METHODS: Prospectively collected data from August 1, 2013, to December 31, 2015, on CLABSI (including MBI-LCBI) from a US PHO multicenter quality improvement network database was analyzed. CDC National Healthcare Safety Network definitions were applied for inpatient events and adapted for ambulatory events. RESULTS: Thirty-five PHO centers reported 401 ambulatory and 416 inpatient MBI-LCBI events. Ambulatory and inpatient MBI-LCBI rates were 0.085 and 1.01 per 1000 line days, respectively. Fifty-three percent of inpatient CLABSIs were MBI-LCBIs versus 32% in the ambulatory setting (P  <  0.01). Neutropenia was the most common criterion defining MBI-LCBI in both settings, being present in ≥90% of events. The most common organisms isolated in MBI-LCBI events were Escherichia coli (in 28% of events), Klebsiella spp. (23%), and viridans streptococci (12%) in the ambulatory setting and viridans streptococci (in 29% of events), E. coli (14%), and Klebsiella spp. (14%) in the inpatient setting. CONCLUSION: In this largest study of PHO MBI-LCBI inpatient events and the first such study in the ambulatory setting, the burden of MBI-LCBI across the continuum of care of PHO patients was substantial. These data should raise awareness of MBI-LCBI among healthcare providers for PHO patients, help benchmarking across centers, and help inform prevention and treatment strategies.

Cluster Randomized Trial Reducing Missed Elevated Blood Pressure in Pediatric Primary Care: Project RedDE.

Recognition of childhood hypertension is essential, but pediatricians routinely fail to identify elevated blood pressure (BP). This study investigated if a quality improvement collaborative (QIC) reduces missed elevated BP in primary care. METHODS: During a cluster-randomized clinical trial, a national cohort worked sequentially to reduce each of three different errors, including missed elevated BP. While working on their first error during an 8-month action period, practices collected control data for a different error. Practices worked to reduce two additional errors in subsequent action periods but continued to provide sustain and maintainenance data on BP. QIC intervention included video learning sessions, transparent data, failures analysis, coaching, and tools to reduce errors. Mixed-effects logistic regression models compared the mean percentage of patients with an elevated BP with appropriate actions taken and documented. RESULTS: We randomized 43 practices and included 30 in the final analysis. Control and intervention phases included 1,728 and 1,834 patients with an elevated BP, respectively. Comparing control versus intervention phases, the mean percentage of patients who received appropriate actions increased from 58% to 74% [risk difference (RD) 16%; 95% CI;12%, 20%]. Practices continued to improve during the sustain phase as compared to the intervention phase (RD 5%; 95% CI; 2%, 9%) and did not worsen during the maintenance phase (RD 0.9%; 95% CI -5%, 7%). CONCLUSIONS: Missed pediatric elevated BP can be sustainably reduced via a QIC intervention, demonstrating a possible model for other error reduction efforts.

Increasing Recognition and Diagnosis of Adolescent Depression: Project RedDE: A Cluster Randomized Trial.

Adolescent depression causes appreciable morbidity and is underdiagnosed in primary care. This study investigated whether a quality improvement collaborative (QIC) increases the frequency of adolescent depression diagnoses, thus reducing missed diagnoses. METHODS: During a cluster-randomized clinical trial, a national cohort of primary care pediatric practices worked in different orders based on randomization to improve performance on each of three different diagnoses; one was increasing adolescent depression diagnoses. While improving their first diagnosis during an 8-month action period, practices collected control data for a different diagnosis. In two subsequent 8-month periods, practices worked to improve two additional diagnoses and continued to provide data on the ability to sustain and maintain improvements. The QIC intervention included day-long video conferences, transparent data sharing, analysis of failures, QI coaching, and tools to help improve diagnostic performance, including the Patient Health Questionnaire-9 Modified. The primary outcome was the measured frequency of depression diagnoses in adolescent health supervision visits compared via generalized mixed-effects regression models. RESULTS: Forty-three practices were randomized with 31 in the final analysis. We included 3,394 patient visits in the control and 4,114 in the intervention phases. The adjusted percentage of patients with depression diagnoses increased from 6.6% in the control to 10.5% in intervention phase (Risk Difference (RD) 3.9%; 95% CI 2.4%, 5.3%). Practices sustained these increases while working on different diagnoses during the second (RD -0.4%; 95% CI -2.3, 1.4%), and third action periods (RD -0.1%; 95% CI -2.7%, 2.4%). CONCLUSIONS: A QIC intervention can sustainably increase adolescent depression diagnoses.

Project RedDE: Cluster Randomized Trial to Reduce Missed or Delayed Abnormal Laboratory Value Actions.

Failure of timely abnormal laboratory result follow-up is relatively common and may lead to harm. This study hypothesized that a quality improvement collaborative (QIC) could reduce the frequency of missed or delayed action on abnormal laboratory values. METHODS: A national cohort of pediatric practices was cluster-randomized to sequentially receive a QIC intervention: video conferences, transparent data sharing, a "focus on failures," QI coaching, and tools to help reduce missed or delayed action on abnormal laboratory values. Practices recorded the percentage of patients with 5 specific abnormal laboratory values who received an appropriate provider action (control), and then, during an 8-month intervention phase, implemented QI strategies to reduce errors (intervention). Subsequently, practices collected data on laboratory errors while working to reduce unrelated second (sustain phase), and third (maintenance phase) errors. Generalized mixed-effects regression models compared the mean percentage of patients with appropriate actions. RESULTS: We randomized 43 practices, of which 31 were included in analyses. Control and intervention phases included 1,357 and 1,426 patients with abnormal laboratory values, respectively. The mean percentage of patients who received appropriate actions did not change comparing control and intervention phases [risk difference (RD) 1%; 95% CI -1%, 3%]. In post-hoc analyses, practices significantly improved comparing control to sustain (RD 3%; 95% CI 0.3%, 6%) and maintenance phases (RD 6%; 95% CI 3%, 9%). CONCLUSION: Implementation of a QIC did not reduce the frequency of abnormal laboratory errors in the initial 8-month intervention phase. A significant reduction was appreciated comparing sustain and maintenance phases (months 9-24) to the control phase.