Regional variation in ICU care for pediatric patients with asthma.

OBJECTIVE: To determine adherence to guidelines for severe asthma care and evaluate regional variability in practice among pediatric intensive care units (PICU). STUDY DESIGN: A retrospective cohort study of children treated for asthma in a PICU during 2000 to 2003. We utilized the Pediatric Health Information System (PHIS) database to identify patients and determine use of asthma therapies when patients did not improve with standard therapy (inhaled beta-agonists and systemic corticosteroids). RESULTS: Of 7125 children studied, 59% received inhaled anticholinergic medications. Use of other therapies included systemic beta-agonists (n = 1841 [26%]), magnesium sulfate (n = 1521 [21%]), methylxanthines (n = 426 [6%]), inhaled helium-oxygen gas mixture (heliox) (n = 740 [10%]), and endotracheal intubation with ventilation (n=1024 [14%]). Use of therapies varied by census region. Over half the patients (n = 524) who received ventilation did so for < or = 1 day. Adjusted for severity of illness, use of mechanical ventilation varied significantly by census division; however, much of the variation was among children ventilated for < or = 1 day. CONCLUSION: Adherence to national guidelines for use of inhaled anticholinergics among critically ill children is low, and marked variation in use of invasive ventilation exists. More explicit guidelines regarding indications for invasive ventilation may improve asthma care.

The effect of surgical case volume on outcome after the Norwood procedure.

OBJECTIVES: We analyze the effect of surgical case volume on the survival of infants with hypoplastic left heart syndrome who underwent stage I surgical palliation (the Norwood procedure). The purpose of our study was to understand more clearly the relative effects of institution and surgeon experience on patient outcome. METHODS: Using the Pediatric Health Information System database belonging to the pediatric hospital members of the Child Health Corporation of America, we identified newborn infants (< 30 days old on admission) from 1998 through 2001 admitted with the diagnosis of hypoplastic left heart syndrome. Stepwise multiple regression analysis was used to examine the association between both institutional and surgeon case volume with 28-day survival after the Norwood procedure. RESULTS: Twenty-nine hospitals and 87 surgeons performed 801 Norwood procedures during the study period. In the 4 of 29 institutions that averaged 1 or more Norwood procedures per month during the study period, survival averaged 78%. The remaining 25 institutions averaged 1 Norwood procedure every 9.6 weeks, with a survival of 59%. Data analysis revealed that higher institutional volume (P = .02) but not the number of cases performed by surgeons (P = .13) increased survival after the Norwood procedure. There was no such association with average length of stay in survivors or the time to mortality in nonsurvivors. CONCLUSION: Survival after the Norwood procedure is associated with institutional Norwood procedure volume but not with individual surgeon case volume, suggesting the need for improvements in institutional-based approaches to the care of children with hypoplastic left heart syndrome and the need for establishing regional referral centers for such high-risk procedures to improve patient survival.

Do on-site patient satisfaction surveys bias results?

BACKGROUND: Response rates, patient sample characteristics, and patient satisfaction ratings were compared between two surveying methods: (1) surveys completed at the physician office site (on-site surveying), and (2) surveys mailed to patient homes following the encounter (mail-out/mail-back). METHODS: Surveying was completed at three physician practices within a 214-physician medical practice. Patients with physician appointments during four-hour time blocks were randomly split to receive either on-site or mail-based satisfaction surveys. RESULTS: Participants younger than 45 years of age provided much higher satisfaction ratings on site than they did by mail (p < .0001), and participants older than 45 years of age reported satisfaction levels consistently whether on site or by mail. Both age groups reported higher satisfaction with "people aspects" of care on site than they did by mail (p < .001). DISCUSSION: On-site methods may yield satisfaction results that are biased in a positive direction for younger patients and for all patients in which social desirability pressures are prominent. Therefore, organizations that rely on such information may have an inflated view of the patient's satisfaction with their care delivery experience. Secondly, because the differences in ratings are the greatest for the "people aspects" of care, if improvement efforts are prioritized on the basis of these rapid results, the wrong priorities may be set.