Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children With Asthma.

OBJECTIVES: Implementation of an asthma clinical practice guideline did not achieve desired chest radiograph (CXR) usage goals. We attempt to use quality improvement methodology to decrease the percentage of CXRs obtained for pediatric patients with acute asthma exacerbations from 29.3% to <20% and to evaluate whether decreases in CXR use are associated with decreased antibiotic use. METHODS: We included all children ≥2 years old at our children's hospital with primary billing codes for asthma from May 2013 to April 2017. A multidisciplinary team tested targeted interventions on the basis of 3 key drivers aimed at reducing CXRs. We used statistical process control charts to study measures. The primary measure was the percentage of patients with an acute asthma exacerbation who were undergoing a CXR. The secondary measure was percentage of patients receiving systemic antibiotics. Balancing measures were all-cause, 3-day return emergency department visits and the percentage of pneumonia and/or asthma codiagnosis encounters. RESULTS: We included 6680 consecutive patients with 1539 CXRs. Implementation of an asthma clinical practice guideline was associated with decreased CXR use from 29.3% to 23.0%. Targeted interventions were associated with further reduction to 16.0%. For subset analyses, CXR use decreased from 21.3% to 12.5% for treat-and-release patients and from 53.5% to 31.1% for admitted patients. Antibiotic use varied slightly without temporal association with interventions or CXR reduction. There were no adverse changes in balancing measures. CONCLUSIONS: Quality improvement methodology and targeted interventions are associated with a sustained reduction in CXR use in pediatric patients with acute asthma exacerbations. Reduction of CXRs is not associated with decreased antibiotic use.

Improved vitamin D supplementation in hospitalized breastfed infants through electronic order modification and targeted provider education.

OBJECTIVE: To examine effectiveness of an intervention promoting vitamin D supplementation in hospitalized breastfed infants. METHODS: Our urban tertiary care hospital instituted a 2-part intervention: brief education for providers on vitamin D guidelines and insertion of an opt-in order for vitamin D supplements into electronic admission order sets. Data downloads on admissions of patients aged <1 year were obtained. We excluded those not breastfed, with a dietary restriction, or admitted to intensive care. Intervention effects were compared from 6 months postintervention to the 6 same months 1 year earlier. We applied χ2 and logistic regression, including the patient as a random effect to adjust for repeated admissions. RESULTS: Data on 471 exclusively or partially breastfed admissions (441 infants) were analyzed (221 preintervention, 250 postintervention). Admission characteristics did not differ by period: 55.0% boys; 40.6% Medicaid; 63.7% hospitalized ≤2 days; 72.0% on a general medical service; 16.6% received nutritionist consultation. In-hospital vitamin D prescribing rates significantly increased postintervention (19.5% vs 44.4%; P<.001). Postintervention admissions were more than twice as likely to receive vitamin D supplementation (adjusted odds ratio 2.3, 95% confidence interval 1.6-3.2). Other associated factors included vitamin D as a medication used before admission (adjusted odds ratio 14.3, 95% confidence interval 4.9-41.6), nutritionist consultation during admission, hospitalization≥3 days, and admission to a general medical service. Prescribing of vitamin D at discharge increased significantly (9.0% vs 19.6%; P<.001). CONCLUSIONS: Medical provider education and modification of electronic ordering templates significantly increased use of vitamin D supplementation in hospitalized breastfed infants.

What parents want from emails with their pediatrician: implications for teaching communication skills.

OBJECTIVE: Physician-patient email communication is increasing but trainees receive no education on this communication medium. Research eliciting patient preferences about email communication could inform training. Investigators elicited parents' perspectives on physician-parent email communication and compared parent and faculty assessments of medical students' emails. METHODS: This mixed methods study explored physician-parent email communication in 5 parent focus groups using qualitative analyses to identify themes. Differences between faculty and parent assessment scores for students' email responses were calculated using univariate general linear modeling. RESULTS: Themes that emerged were: (1) Building the Relationship, (2) Clarity of Communication and (3) Expectations. Parents criticized student's statements as condescending. The sum of assessment scores by parents and faculty were moderately correlated (r(44)=.407, P<.01), but parents gave students lower scores on "acknowledges validity/expresses empathy" (P=.01) and higher scores on "provides next steps" (P<.01) and "identifies issues" (P<.01). CONCLUSION: Parents place value on students' abilities to communicate clearly and convey respect and empathy in email. Parent and faculty perspectives on email communication are similar but not the same. PRACTICE IMPLICATIONS: Differences between parental and faculty assessments of medical students' emails supports the need for the involvement of patients and families in email communication curriculum development.

Health-related quality of life in patients with congenitally corrected transposition of the great arteries.

OBJECTIVE: The study's objectives were to survey the quality of life in patients with congenitally corrected transposition of the great arteries and to compare the responses of those who have undergone anatomic repair with those who have a systemic right ventricle. METHODS: Thirty-eight patients who underwent anatomic repair and 13 patients after either conventional repair or no surgical procedure were enrolled. Subjects completed the PedsQL 4.0 Generic and 3.0 Cardiac Modules. Scores were also compared with those of patients from the literature with at least moderately severe cardiovascular disease. Mean differences between groups were compared, and the association between clinical variables and score in the anatomic repair subgroup was measured. RESULTS: Caregivers of patients in the anatomic repair group reported similar scores compared with the non-anatomic repair group in all functional domains The anatomic repair group self-reported lower school function (63 vs 81, P = .02). On the Cardiac Module, patients in the anatomic repair group self-reported fewer problems related to residual heart disease (75 vs 63), appearance (81 vs 68), and treatment anxiety (74 vs 59), although the differences were not significant. Compared with patients with other heart disease, the anatomic repair group scored lower, with the largest differences in cognition and communication. Prolonged hospital stay and need for a pacemaker were associated with lower quality of life after anatomic repair. CONCLUSIONS: Patients in the anatomic repair group had similar quality of life compared with patients in the non-anatomic group, except in the domain of school functioning. Prolonged hospital stay and need for a pacemaker after anatomic repair may be risk factors for lower quality of life.