Data-driven order set generation and evaluation in the pediatric environment.

Order sets as part of the Computerized Provider Order Entry (CPOE) system can improve care delivery through allowing faster and easier physician order entry guided by known best practices. This study examines current utilization patterns of order sets and "a la carte" orders in a pediatric environment with a preliminary investigation of methods to automate the creation and modification of order sets using historical ordering data. We examine the current usage of order sets associated with Asthma Minor and Appendectomy Minor patients to understand how physicians are utilizing order sets, and how order set usage is associated with the time of ordering and characteristics of order sets. K-means clustering was applied to orders to generate evidence-based order sets that are learned from historical hospital data. We demonstrate that coverage rate of order sets and ordering efficiency can be increased through modifications of existing sets and creation of new sets.

Who are portal users vs. early e-Visit adopters? A preliminary analysis.

Patient portals and eVisits are gaining momentum due to increasing consumer demand for improved access to clinical information and services, availability of new technologies to deploy them and development of reimbursement initiatives by major payers. Despite increasing interest in online health consultation by consumers, adoption has been slow and little is known about the users of such services. In this study, we analyze the key features that distinguish early adopters of eVisits from portal consumers, in aggregate and in four distinct ambulatory practices, using data from a major healthcare provider in Western Pennsylvania. Preliminary results indicate that out of 10,532 portal users, the 336 patients who submitted 446 eVisits between April 1, 2009 and May 31, 2010 are younger on average, predominantly female, not retired, but in poorer health condition. They access the portal more frequently, indicating that they are potentially more involved in managing their health. Using fixed-effects logistic regression models to compare across practices, we note that practice indicator is a significant predictor of eVisit usage, perhaps due to the varying strategies used to build awareness and encourage adoption. Despite the small difference in out-of-pocket payment for eVisits covered by insurance vs. otherwise, insurance coverage for eVisits significantly contributes to increased usage. In ongoing work, additional characteristics of patients and practices that have access to the patient portal will be used to better delineate patients' choice of eVisit vs. the traditional office visit.

A clustering approach to segmenting users of internet-based risk calculators.

BACKGROUND: Risk calculators are widely available Internet applications that deliver quantitative health risk estimates to consumers. Although these tools are known to have varying effects on risk perceptions, little is known about who will be more likely to accept objective risk estimates. OBJECTIVE: To identify clusters of online health consumers that help explain variation in individual improvement in risk perceptions from web-based quantitative disease risk information. METHODS: A secondary analysis was performed on data collected in a field experiment that measured people's pre-diabetes risk perceptions before and after visiting a realistic health promotion website that provided quantitative risk information. K-means clustering was performed on numerous candidate variable sets, and the different segmentations were evaluated based on between-cluster variation in risk perception improvement. RESULTS: Variation in responses to risk information was best explained by clustering on pre-intervention absolute pre-diabetes risk perceptions and an objective estimate of personal risk. Members of a high-risk overestimater cluster showed large improvements in their risk perceptions, but clusters of both moderate-risk and high-risk underestimaters were much more muted in improving their optimistically biased perceptions. CONCLUSIONS: Cluster analysis provided a unique approach for segmenting health consumers and predicting their acceptance of quantitative disease risk information. These clusters suggest that health consumers were very responsive to good news, but tended not to incorporate bad news into their self-perceptions much. These findings help to quantify variation among online health consumers and may inform the targeted marketing of and improvements to risk communication tools on the Internet.

Design of a donor-driven data collection strategy for operational improvement of blood donation process.

BACKGROUND: Prior studies have noted that donor retention may be negatively impacted by the total time it takes to complete the blood donation process. STUDY DESIGN AND METHODS: To gain a comprehensive understanding of the blood donation process and examine opportunities for operational improvements, an educational partnership established between a blood bank and a university designed and implemented a donor-driven data collection strategy. RESULTS: A large amount of real-time, comprehensive, donor-reported data was collected as donors navigated the process, which has enabled a thorough analysis of the process and its potential improvements. CONCLUSION: In this paper, we describe the design and implementation efforts, examine the challenges in operationalizing a donor-driven data collection approach, and present insights and recommendations for its application in similar settings.

Pleural space disease in pediatric patients: a retrospective analysis.

Pleural space disease, pleural effusions, and parapneumonic empyema present a therapeutic dilemma regarding the most appropriate medical and surgical management (i.e., performing a thoracentesis on admission versus delayed, placing a pigtail catheter versus a regular chest tube, and performing early versus late thoracoscopy). Other questions remain about early surgical intervention to decrease morbidity, shorten hospital stay, and produce cost-effective results. To define a clinical approach for a prospective study, the charts of all patients who were discharged with ICD-9 codes 511.8, 511.9, and 510.9, between June 5, 1991, and May 7, 1995, were reviewed. Thirty-one patients were identified. A database was developed and the results were analyzed. This paper presents a clinical pathway suggested by this retrospective study with cost analysis.

Determinants of information technology outsourcing among health maintenance organizations.

We analyze the determinants of HMO information technology outsourcing using two studies. Study 1 examines the effect of asset specificity on outsourcing for development and operation activities, using HMO specific fixed effects to control for differences between HMOs. Study 2 regresses the HMO specific fixed effects from Study 1, which measure an HMO's propensity to outsource, on HMO characteristics. The data comes from a 1995 InterStudy survey about information technology organization of HMOs. While HMOs split roughly equally in outsourcing information technology development activities, they are extremely unlikely to outsource the day-to-day operation of information systems. The greater an HMO's information technology capability and the complexity of information systems supported, the less likely is an HMO to outsource. While HMOs less than two years old, for-profit HMOs, local or Blue Cross-affiliated HMOs, and mixed HMOs are more likely to outsource, federally qualified HMOs are less likely to outsource. Policy and managerial implications for the adoption and diffusion of new ways of organizing information technology, such as application service providers (ASPs), are discussed.

The child with persistent cough.

Coughing is a healthy reflex. Causes of a cough can vary from minor upper respiratory illnesses to malignancy. When a child's cough continues for weeks, parents worry. Primary care providers must decide when reassessment is needed and if a vigorous workup and referral to a pulmonologist are required. The above discussion should assist these physicians.

The diffusion of information technology among health maintenance organizations.

This article examines the information technology functions, staffing and cost, services provided, and advanced technologies among health maintenance organizations (HMOs) using a national sample of HMOs from mid-1995. HMOs have a well-developed capability to use data from administrative functions, such as claims processing. Nationally affiliated HMOs and HMOs in markets with greater HMO penetration support more IT functions. Relatively little work has been completed integrating clinical with administrative systems.

Effects of Pseudomonas colonization on body composition and resting energy expenditure in children with cystic fibrosis.

BACKGROUND: To determine the extent and effects of increased metabolic demand represented by Pseudomonas colonization on body composition and resting energy expenditure in children with cystic fibrosis (CF). METHODS: The study comprised 18 stable children with CF, of whom 10 (6 male/4 female) were colonized with Pseudomonas species and 8 (4 male/4 female) were not. The groups were of similar age range and genotype. Measured resting energy expenditure (REE) was performed by open circuit indirect calorimetry and compared with predicted REE calculated from standard equations. Body composition was determined by dual-energy x-ray absorptiometry, including lean body mass (LBM), fat mass (FM), bone mineral density (BMD), and anterior-posterior spine density (APS); these were compared using z-scores. Routine pulmonary function testing assessed forced vital capacity, forced expiratory volume in 1 second (FEV1), and forced expiratory flow over middle half of vital capacity (FEF25% to 75%); these were compared as percent predicted. RESULTS: As expected, results of pulmonary function testing showed significant deterioration among the children colonized with Pseudomonas species when compared with the children who were not, while standard anthropometry showed no differences in weight, height, or weight-for-height percentile and respective z-scores. Although a trend of lower LBM was noted among the children colonized with Pseudomonas species, no significant differences were found between these children and children who were not colonized with Pseudomonas species when z-scores for LBM, FM, BMD, or APS were compared during body composition analysis. In addition, neither REE as kilocalories per day (kcal/d) nor REE expressed as a percent predicted by standard equations discriminated between subgroups of children colonized with Pseudomonas species and children who were not. However, metabolic demand, expressed as resting energy expenditure in kilocalories per kilogram (kcal/kg) of LBM (REE/LBM), revealed significant differences between children colonized with Pseudomonas species and children who were not (75.4+/-4.4 vs 58.6+/-2.9 kcal/kg, p < .05). CONCLUSIONS: The effect of Pseudomonas colonization on metabolic demand in children with CF can be accurately assessed by expressing resting energy expenditure as kilocalorie per kilogram of LBM, the active metabolic component of the body. The 50% increase in REE/LBM seen in the children colonized with Pseudomonas species represents the metabolic demand from the inflammatory burden and work of breathing resulting from the effects of the Pseudomonas colonization. The trend of a lower LBM in the children colonized with Pseudomonas species makes this finding even more dramatic.

Effects of the flutter device on pulmonary function studies among pediatric cystic fibrosis patients.

PURPOSE: Previous studies have shown that the Scandipharm Flutter airway clearance device has increased the ability of cystic fibrosis patients to expectorate mucus. Studies that show the effects of the Flutter on pulmonary function among the pediatric cystic fibrosis patients are limited. Thus, we embarked on a study to assess the device's effectiveness. METHODS: The long-term effect of the Flutter on pulmonary function tests (PFTs) was studied and compared with other airway clearance techniques, such as chest physiotherapy (CPT) and Vital Signs, Inc. 9000 PEP positive expiratory pressure (PEP) therapy for cystic fibrosis patients of five to 17 years of age with mild to moderate disease. Of the 15 patients who qualified, six completed the study. The patients were evaluated using PFTs and a respiratory assessment at the beginning and end of each new therapy. Duration of each therapy was one month. RESULTS: No respiratory assessment parameters changed between the therapies studied. All patients who used the Flutter preferred it over the other two therapies. The patients stated they felt better clinically, were able to expectorate mucus more easily, and felt more in control of their therapies. Paired t-test statistical analysis from the PFT data indicated no significant changes in forced expiratory volume in the first second of expiration (FEV1), forced expiratory flow from 25 percent to 75 percent of the loop (FEF25-75), airway resistance (Raw), or specific airway conductance (sGaw) among the three therapies studied. CONCLUSION: This study has shown no significant change in respiratory assessment parameters or pulmonary function. Further studies involving multicenter trials are warranted to evaluate the effects of the Flutter on pulmonary function.

Noninvasive ventilation via bilevel positive airway pressure support in pediatric practice.

OBJECTIVE: To evaluate the efficacy of bilevel positive airway pressure support in critically ill children with underlying medical conditions. DESIGN: Prospective, clinical study. SETTING: Pediatric intensive care unit (ICU). PATIENTS: Thirty-four patients (6 mos to 20 yrs, mean 11.06 +/- 0.9 yrs) with impending respiratory failure were enrolled in the study. All patients required airway or oxygenation/ventilation support (awake or asleep) and required admission to our pediatric ICU. Each patient served as his or her own control. Exclusion criteria were absent cough or gag reflex, multiple organ system failure, age of <6 mos, vocal cord paralysis, and noncooperation with nasal mask. INTERVENTIONS: Bilevel positive airway pressure support ventilation. MEASUREMENTS AND MAIN RESULTS: Thirty-four patients with 35 episodes of respiratory insufficiency requiring airway support or oxygenation/ventilatory support were treated with bilevel positive airway pressure support ventilation. Dyspnea score decreased at least two deviations in all patients; dyspnea score decreased five deviations in 67% of patients. Resting heart rate decreased from 126 +/- 3.2 to 102 +/- 3.2 beats/min (p < .001), respiratory rate decreased from 39 +/- 3 to 25 +/- 1 breaths/min (p < .004), bicarbonate concentrations decreased from 30.0 +/- 1.0 to 24.0 +/- 0.7 mmol/L (p < .01), and room air saturation increased from 85 +/- 2% to 97 +/- 1%. Bilevel positive airway pressure support ventilation failure was characterized by an inability to stabilize progression of respiratory failure and the subsequent placement of an artificial airway. Three patients required placement of an artificial airway. CONCLUSIONS: A decrease in respiratory rate, heart rate, and dyspnea score and an improvement in oxygenation were noted in >90% of patients studied, resulting in only an 8% frequency of intubation. The efficacy of bilevel positive airway pressure support ventilation in selected groups of patients indicates the need to include this form of noninvasive pressure support ventilation in the care offered by pediatric ICUs.

Use of BiPAP by nasal mask in the treatment of respiratory insufficiency in pediatric patients: preliminary investigation.

A device for nasally applied bilevel positive airway pressure, BiPAP (Respironics Inc., Murrysville, PA), is currently being evaluated for the treatment of respiratory failure in pediatric and adult patients. This retrospective case review examines our experience with using BiPAP in the treatment of acute ventilatory deterioration in pediatric patients with chronic respiratory insufficiency. All patients who presented to the intensive care unit with chronic respiratory insufficiency and ventilatory failure but without hypoxia were given a trial on BiPAP. Fifteen patients, ages 4-21 years, received such ventilatory support. Four of them had cystic fibrosis (CF) and 11 had neuromuscular disease (2, spinal muscular atrophy; 7, Duchenne muscular dystrophy; 1, spinal cord injury; and 1, myopathy of undetermined origin). Hospital days, respiratory rates, resting heart rates, arterial blood gases, serum bicarbonates, and subjective assessment by parents and or patients of dyspnea, sleep pattern, and activity tolerance were compared prior to and after initiation of BiPAP. Patients were followed from 1 day to 21 months. In 14 of 15 patients placement of an artificial airway could be avoided. Significant decreases in hospital days, respiratory rate, heart rate, serum bicarbonate, and arterial PCO2 were observed after initiation of BiPAP. Decline in dyspnea (87% with severe distress at rest prior vs. 80% comfortable at rest after BiPAP), increased activity tolerance (57% attending school after BiPAP vs. none prior to BiPAP), and improved quality of sleep (93% with comfortable sleep, no daytime somnolence vs. none with comfortable sleep and 36% with daytime somnolence prior to BiPAP).(ABSTRACT TRUNCATED AT 250 WORDS)

Innominate artery compression of the trachea: relationship to cervical herniation of the normal thymus.

PURPOSE: To document the possible association of segmental tracheomalacia in the thoracic inlet with the combination of a large thymus and normal innominate artery. MATERIALS AND METHODS: Eight infants with symptoms of innominate artery compression of the trachea were studied. The diagnostic approach included observation of posterior tracheal displacement and focal tracheal collapse at fluoroscopy, ablation of the right radial pulse by rigid endoscopic pressure, and compression of the anterior tracheal wall by the innominate artery at magnetic resonance imaging. RESULTS: Six patients had relief of symptoms with either thymectomy and innominate artery reimplantation (n = 4) or subtotal thymectomy and innominate artery suspension (n = 2). The ratio of the sagittal diameter of the thymus to the sagittal diameter of the thoracic inlet was significantly (P < .0009) higher in the symptomatic patients (0.58 +/- 0.03) than in age-matched control subjects (0.35 +/- 0.08). CONCLUSION: Crowding of the thoracic inlet by cervical herniation of an enlarged but normal thymus may contribute to the development of tracheomalacia and the symptoms of innominate artery compression.

Complications of tracheostomy and decannulation in pediatric and young patients with traumatic brain injury.

Tracheostomy is indicated for many patients who are in a prolonged comatose state. The procedure in children is believed to be associated with a higher morbidity and mortality; however, most studies have focused on adult patients. Thus, to better define the incidence, a retrospective study was done on 30 head injured pediatric patients who had tracheostomies at our rehabilitation institution. In 26 patients tracheostomy was indicated for prolonged hyperventilation. The average duration of tracheostomy was 49 days. Twenty-six total complications (86.6%) were reported within seven days of tracheostomy; pneumonia was the most common. Twenty-seven late complications (90%) were reported, with tracheal granuloma being the most common. Ten patients (58%) were successfully decannulated during rehabilitation; seven tracheostomies remained patent when patients were discharged. Results of this study confirm the high rate of airway complications in traumatic brain injury pediatric patients and suggest that most occur within 50 days of intubation. Limiting artificial airway management to less than approximately 50 days may markedly reduce airway complications in the pediatric TBI patient.

Intrapleural streptokinase as adjunctive treatment for persistent empyema in pediatric patients.

Successful treatment of persistent empyema by intrapleural streptokinase is described in five pediatric patients. Their ages ranged from 18 months to 7 years. All experienced dramatic improvement in the resolution of their empyemas following intrapleural streptokinase. Improved chest tube drainage occurred concurrently with clinical improvement. Intrapleural instillation of streptokinase appears to be a safe adjunctive therapeutic tool to facilitate drainage of persistent empyema in the small number of pediatric patients in whom it has been employed. Additional study will be required to further assess the long-term therapeutic efficacy and consequences of intrapleural streptokinase therapy.

Cervical trachea: dynamics in response to herniation of the normal thymus.

Nineteen infants aged 2 months to 2.5 years, first seen predominantly with stridor, were noted to have intermittent soft-tissue mass effect in the upper airway during routine evaluation with fluoroscopic or radiographic methods. The cervicothoracic trachea was always buckled posteriorly and, in almost all instances, to the right during forced exhalation (crying). Real-time ultrasound examination with the neck extended was used in these patients to define the cause of the tracheal dynamics. The intermittent cephalic movement of the homogeneous echotextured thymus from the anterior mediastinum into the neck was determined to be the probable cause of the mass effect in these infants. Magnetic resonance imaging in three infants confirmed this finding. The intermittent, physiologic suprasternal movement of the thymus in these infants did not by itself cause any luminal compromise of the trachea and did not result in any respiratory difficulty in these infants.

Outcome of short-term hospitalization for children with severe asthma.

This study presents results of a family-centered, short-term residential program in which medical, behavioral, and treatment assessments were provided to the child with severe asthma and the family. After a median stay of 15 days, forty-four consecutively admitted children with severe asthma achieved a 93% reduction in hospital days (median, 7 hospital days for the year before treatment versus median 0 hospital days per patient per year at 20 1/2-month follow-up; p less than 0.001) and an 81% reduction in emergency care (median, 4 visits for the year previously versus median, 0.4 visits per patient per year at follow-up; p less than 0.01). There was also a significant reduction in corticosteroid bursts and improvement in FEV1. Unique to this program was mandatory family participation focusing on the child's and family's adaptation to severe asthma and development of family-specific interventions to promote compliance with the treatment regimen. Child and family functioning was assessed at admission and follow-up. Hospital use at follow-up was greater for children from dysfunctional families. Families demonstrating difficulties in disciplining the child with asthma required more hospital days both before admission and at follow-up. Short-term hospitalization for children with severe asthma is associated with significant improvement in pulmonary morbidity when the family of the child is included in assessment and treatment.

Nocturnal negative pressure ventilation.

In this study, 25 patients between the ages of 12 and 24 years who had neuromuscular diseases, a vital capacity less than 50 percent of predicted, and a history suggestive of nocturnal hypoventilation were observed with overnight monitoring of end-tidal CO2 (EtCO2) and O2 saturation (SaO2). Those patients with a strong clinical history and evidence of nocturnal hypoventilation (increased EtCO2 of 50 to 70 torr and decreased SaO2 [less than 90 percent]) (10 patients) were placed on nocturnal negative pressure ventilation (NNPV). Admission, treatment, and posttreatment arterial blood gases were analyzed by paired statistical "t" tests. Comparison of mean PaO2 values obtained on admission with those obtained during treatment revealed a greater than 97.5 percent confidence (p = 0.025; n = 7). Mean PaO2 values obtained after treatment (off negative pressure ventilation [NPV], awake during daytime) were 65.9 +/- 18.2 mmHg and 79.0 + 14.5 mmHg, respectively (p = 0.005; n = 6). Comparison of post-treatment PaO2 values as a percentage of admission (pretest) values showed a significant change at the 0.5 percent level with an applied Wilcoxan Signed-ranks Matched-pairs Test. The mean PaCO2 values obtained upon admission and those obtained during treatment were 53.7 +/- 15.1 mmHg and 48.1 +/- 14.2 mmHg, respectively (p = 0.05; n = 7), and comparison mean PaCO2 values obtained upon admission and after treatment were 57.9 +/- 16.0 mmHg and 51.2 +/- 7.0 mmHg, respectively (p = 0.1; n = 6).(ABSTRACT TRUNCATED AT 250 WORDS)