Parental Mental Health and Childhood Respiratory Outcomes in a Severe Bronchiolitis Cohort.

Parental mental health conditions appear to contribute to the development of childhood respiratory illness. We investigated the relationship between parental mental health and childhood respiratory illness using data from a 17-center prospective cohort study of infants hospitalized with bronchiolitis between 2011 and 2014 (n = 921). Among 779 (84.6%) participants with self-reported parental mental health history data, 184 (23.6%) had parental history of depression and 155 (19.9%) had anxiety. Multivariable analyses found that both parental history of depression (hazard ratio [HR] 1.41, 95% confidence interval [CI] 1.01-1.99) and anxiety (HR 1.28, 95% CI 1.08-1.52) were associated with an increased risk of recurrent wheezing by age 3 years. However, only parental history of anxiety was associated with asthma by age 5 years (odds ratio 1.79, 95% CI 1.25-2.55). Further research on exposure severity, other early life stressors, and effective methods of parental psychosocial support is needed to develop targeted risk factor prevention strategies to reduce the burden of childhood respiratory illness.

Hospital's observed specific standard practice: A novel measure of variation in care for common inpatient pediatric conditions.

BACKGROUND: Previously few means existed to broadly examine variability across conditions/practices within or between hospitals for common pediatric conditions. OBJECTIVE: Our objective was to develop a novel empiric measure of variation in care and test its association with patient-centered outcomes. DESIGNS: We conducted a retrospective cohort study of children hospitalized from January 2016 to December 2018 using the Pediatric Hospital Information Systems database. SETTINGS AND PARTICIPANTS: We included children ages 0-18 years hospitalized with asthma, bronchiolitis, or gastroenteritis. INTERVENTION: We developed a hospital-specific measure of variation in care, the hospital's observed specific standard practice (HOSSP), the most common combination of laboratory studies, imaging, and medications used at each hospital. MAIN OUTCOME AND MEASURES: The outcomes were standardized costs, length of stay (LOS), and 7-day all-cause readmissions. RESULTS: Among 133,392 hospitalizations from 41 hospitals (asthma = 50,382, bronchiolitis = 54,745, and gastroenteritis = 28,265), there was significant variation in overall HOSSP adherence across hospitals for these conditions (asthma: 3.5%-47.4% [p < .001], bronchiolitis: 2.5%-19.8% [p < .001], gastroenteritis: 1.6%-11.6% [p < .001]). The majority of HOSSP variation was driven by differences in medication prescribing for asthma and bronchiolitis and laboratory ordering for gastroenteritis. For all three conditions, greater HOSSP adherence was associated with significantly lower hospital costs (asthma: p = .04, bronchiolitis: p < .001, acute gastroenteritis: p = .01), without increases in LOS or 7-day all cause readmissions. CONCLUSION: We found substantial variation in the components and adherence to HOSSP. Hospitals with greater HOSSP adherence had lower costs for these conditions. This suggests hospitals can use data around laboratory, imaging, and medication prescribing practices to drive standardization of care, reduce unnecessary testing and treatment, determine best practices, and reduce costs.

Reducing Invasive Care for Low-risk Febrile Infants Through Implementation of a Clinical Pathway.

BACKGROUND AND OBJECTIVES: Significant variation in management of febrile infants exists both nationally and within our institution. Risk stratification can be used to identify low-risk infants who can be managed as outpatients without lumbar puncture (LP) or antibiotics. Our objective was to reduce invasive interventions for febrile infants aged 29 to 60 days at low risk for serious bacterial infection (SBI) through implementation of a clinical pathway supported by quality improvement (QI). METHODS: The evidence-based clinical pathway was developed and implemented by a multidisciplinary team with continuous-process QI to sustain use. Low-risk infants who underwent LP, received antibiotics, and were admitted to the hospital were compared pre- and postpathway implementation with SBI in low-risk infants and appropriate care for high-risk infants as balancing measures. RESULTS: Of 350 included patients, 220 were pre- and 130 were postpathway implementation. With pathway implementation in July 2016, invasive interventions decreased significantly in low-risk infants, with LPs decreasing from 32% to 0%, antibiotic administration from 30% to 1%, and hospital admission from 17% to 2%. Postimplementation, there were 0 SBIs in low-risk infants versus 29.2% in high-risk infants. The percentage of high-risk patients receiving care per pathway remained unchanged. Improvement was sustained for 12 months through QI interventions, including order-set development and e-mail reminders. CONCLUSIONS: Implementation of a clinical pathway by using QI methods resulted in sustained reduction in invasive interventions for low-risk febrile infants without missed SBIs. Clinical pathways and QI can be key strategies in the delivery of evidence-based care for febrile infants.

Osteoporosis risk in frail older adults in assisted living.

OBJECTIVES: To compare osteoporosis risk in residents of assisted living (AL) with that of age- and sex-matched community-dwelling adults. DESIGN: Cross-sectional. SETTING: Community and AL facilities in Connecticut. PARTICIPANTS: One hundred seven individuals (77 control, 37 AL). ASSESSMENTS: Fracture and osteoporosis evaluation history, qualitative heel ultrasound (QUS), 25-hydroxyvitamin D (25OHD), parathyroid hormone (PTH), and physical function measures, including walking speed, chair rise time, 6-minute walk, Berg Balance Scale, Get Up and Go, and handgrip strength. RESULTS: Participants' mean age was 82.7+/-5.7. There were no group differences in reported fracture, diagnosis of osteoporosis, or previous bone mineral density (BMD) assessment. QUS T-scores were -1.0+/-1.5 for community living and -1.9+/-1.3 for AL (P=.002), 25OHD levels were 113.0+/-40.1 nnmol/L for community living and 81.8+/-36.9 for AL (P<.001), and PTH levels were 50.8+/-29.8 pg/mL for community living and 58.8+/-32.8 pg/mL for AL (P=.22). Physical performance was more impaired in AL (P<.05), except for single leg stance (P=.16). In linear regression analysis, age, sex, and site of residence were significant predictors of heel T-score, explaining 53.7% of the variance. CONCLUSION: Residents of AL did not report less fracture or osteoporosis than those from the community, but risk factors measured directly were significantly different, including lower BMD and 25OHD and more impairment in measures of physical function. These data suggest that residents of AL are at greater risk for osteoporotic fracture and that measures to diminish risk (optimizing vitamin D status, implementing fall prevention strategies, incorporating exercise to improve physical performance) should be considered and studied for benefit.

Association between level of frailty and bone mineral density in community-dwelling men.

The goal of this study is to determine the associations between the components of a frailty definition and bone mineral density (BMD) in older men. A total of 392 community dwelling men (age range: 58-95 yr) with a mean age of 73+/-8 yr were evaluated. Femoral neck BMD T-scores ranged from -5.78 to +2.50, with 48.7% who had T-scores between -1 and -2.5 (low bone mass) and 8.7% who had T scores < or = -2.5 (osteoporosis). Participants were characterized as normal (39%), intermediate (55%), or frail (6%). Hand grip strength was 31.5+/-9.1 kg in those with normal BMD compared with 26.5+/-7.9 kg in those with osteoporotic BMD (p=0.0026). Walk speed (8 ft) was 2.32+/-0.49 s in those with normal BMD compared with 2.87+/-1.30 s with osteoporotic BMD (p=0.0015). Femoral neck T-score declined significantly with increasing level of frailty (p=0.014), but significance of decline was lost when corrected for age. Increasing frailty was associated with lower femoral neck BMD, although the association was not independent of age. Two components of the frailty model (i.e., hand grip strength and walking speed) were independently associated with lower femoral neck BMD, a finding that has not previously been reported in men.