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1.  The Joint Commission Children’s Asthma Care Quality Measures and Asthma Readmissions 
Pediatrics  2012;130(3):482-491.
The Joint Commission introduced 3 Children’s Asthma Care (CAC 1–3) measures to improve the quality of pediatric inpatient asthma care. Validity of the commission’s measures has not yet been demonstrated. The objectives of this quality improvement study were to examine changes in provider compliance with CAC 1–3 and associated asthma hospitalization outcomes after full implementation of an asthma care process model (CPM).
The study included children aged 2 to 17 years who were admitted to a tertiary care children’s hospital for acute asthma between January 1, 2005, and December 31, 2010. The study was divided into 3 periods: preimplementation (January 1, 2005–December 31, 2007), implementation (January 1, 2008–March 31, 2009), and postimplementation (April 1, 2009–December 31, 2010) periods. Changes in provider compliance with CAC 1–3 and associated changes in hospitalization outcomes (length of stay, costs, PICU transfer, deaths, and asthma readmissions within 6 months) were measured. Logistic regression was used to control for age, gender, race, insurance type, and time.
A total of 1865 children were included. Compliance with quality measures before and after the CPM implementation was as follows: 99% versus 100%, CAC-1; 100% versus 100%, CAC-2; and 0% versus 87%, CAC-3 (P < .01). Increased compliance with CAC-3 was associated with a sustained decrease in readmissions from an average of 17% to 12% (P = .01) postimplementation. No change in other outcomes was observed.
Implementation of the asthma CPM was associated with improved compliance with CAC-3 and with a delayed, yet significant and sustained decrease in hospital asthma readmission rates, validating CAC-3 as a quality measure. Due to high baseline compliance, CAC-1 and CAC-2 are of questionable value as quality measures.
PMCID: PMC4074621  PMID: 22908110
asthma; compliance; hospitalization; quality improvement; quality of care
2.  Longitudinal Validation of a Tool for Asthma Self-Monitoring 
Pediatrics  2013;132(6):e1554-e1561.
To establish longitudinal validation of a new tool, the Asthma Symptom Tracker (AST). AST combines weekly use of the Asthma Control Test with a color-coded graph for visual trending.
Prospective cohort study of children age 2 to 18 years admitted for asthma. Parents or children (n = 210) completed baseline AST assessments during hospitalization, then over 6 months after discharge. Concurrent with the first 5 AST assessments, the Asthma Control Questionnaire (ACQ) was administered for comparison.
Test–retest reliability (intraclass correlation) was moderate, with a small longitudinal variation of AST measurements within subjects during follow-ups. Internal consistency was strong at baseline (Cronbach’s α 0.70) and during follow-ups (Cronbach’s α 0.82–0.90). Criterion validity demonstrated a significant correlation between AST and ACQ scores at baseline (r = −0.80, P < .01) and during follow-ups (r = −0.64, −0.72, −0.63, and −0.69). The AST was responsive to change over time; an increased ACQ score by 1 point was associated with a decreased AST score by 2.65 points (P < .01) at baseline and 3.11 points (P < .01) during follow-ups. Discriminant validity demonstrated a strong association between decreased AST scores and increased oral corticosteroid use (odds ratio 1.13, 95% confidence interval, 1.10–1.16, P < .01) and increased unscheduled acute asthma visits (odds ratio 1.23, 95% confidence interval, 1.18–1.28, P < .01).
The AST is reliable, valid, and responsive to change over time, and can facilitate ongoing monitoring of asthma control and proactive medical decision-making in children.
PMCID: PMC4074668  PMID: 24218469
asthma control; pediatrics; self-monitoring; self-management
3.  The Strategic Planning Committee Report: The First Step in a Journey to Recognize Pediatric Hospital Medicine as a Distinct Discipline 
Hospital pediatrics  2012;2(4):187-190.
The field of pediatric hospital medicine (PHM) has experienced phenomenal growth over the past decade. Academic contributions by pediatric hospitalists include the creation of PHM core competencies,1 national collaborative PHM networks for both research (the Pediatric Research in Inpatient Settings network2) and quality improvement (the Value in Inpatient Pediatrics network3), a robust and well-attended annual scientific meeting,4 and an increasing number of divisions or sections of PHM in pediatric departments across the country. Many pediatricians are choosing to pursue careers in PHM,5,6 and several postgraduate training programs for PHM have emerged.7 Similar to other generalist pediatric fields,8-11 the question as to how best for PHM to evolve as a distinct discipline has arisen. Several training and/or certification options are feasible and have been examined by the pediatric hospitalists who constitute the Strategic Planning (STP) Committee. The objectives of this commentary are to (1) describe the work done to investigate these options to date, (2) provide a framework for evaluating them, and (3) describe next steps. This commentary will neither justify subspecialty status for PHM, which is currently still debated within the field, nor will it compare the development of PHM as a subspecialty with other generalist fields because such a comparison is premature.
PMCID: PMC4068346  PMID: 24313023
5.  Development of a Novel Tool for Engaging Children and Parents in Asthma Self-Management 
This paper describes the development and evaluation of an innovative application designed to engage children and their parents in weekly asthma self-monitoring and self-management to prompt an early response to deteriorations in chronic asthma control, and to provide their physicians with longitudinal data to assess the effectiveness of asthma therapy and prompt adjustments. The evaluation included 2 iterative usability testing cycles with 6 children with asthma and 2 parents of children with asthma to assess user performance and satisfaction with the application. Several usability problems were identified and changes were made to ensure acceptability of the application and relevance of the content. This novel application is unique compared to existing asthma tools and may shift asthma care from the current reactive, acute care model to a preventive, proactive patient-centered approach where treatment decisions are tailored to patients’ individual patterns of chronic asthma control to prevent acute exacerbations.
PMCID: PMC3540453  PMID: 23304339
6.  Factors associated with intern noncompliance with the 2003 Accreditation Council for Graduate Medical Education’s 30-hour duty period requirement 
BMC Medical Education  2012;12:33.
In 2003 the Accreditation Council for Graduate Medical Education mandated work hour restrictions. Violations can results in a residency program being cited or placed on probation. Recurrent violations could results in loss of accreditation. We wanted to determine specific intern and workload factors associated with violation of a specific mandate, the 30-hour duty period requirement.
Retrospective review of interns’ performance against the 30-hour duty period requirement during inpatient ward rotations at a pediatric residency program between June 24, 2008 and June 23, 2009. The analytical plan included both univariate and multivariable logistic regression analyses.
Twenty of the 26 (77%) interns had 80 self-reported episodes of continuous work hours greater than 30 hours. In multivariable analysis, noncompliance was inversely associated with the number of prior inpatient rotations (odds ratio: 0.49, 95% confidence interval (0.38, 0.64) per rotation) but directly associated with the total number of patients (odds ratio: 1.30 (1.10, 1.53) per additional patient). The number of admissions on-call, number of admissions after midnight and number of discharges post-call were not significantly associated with noncompliance. The level of noncompliance also varied significantly between interns after accounting for intern experience and workload factors. Subject to limitations in statistical power, we were unable to identify specific intern characteristics, such as demographic variables or examination scores, which account for the variation in noncompliance between interns.
Both intern and workload factors were associated with pediatric intern noncompliance with the 30-hour duty period requirement during inpatient ward rotations. Residency programs must develop information systems to understand the individual and experience factors associated with noncompliance and implement appropriate interventions to ensure compliance with the duty hour regulations.
PMCID: PMC3398848  PMID: 22621439
7.  Sustaining Compliance with Pediatric Asthma Inpatient Quality Measures 
To reduce readmission risk in children hospitalized with asthma, The Joint Commission (JC) mandated hospitals to initiate preventive measures and provide patients/caregivers with a home management plan of care (HMPC) at discharge. Standard methods for recording HMPC compliance require hospitals to commit considerable resources. We developed an asthma-specific “reminder and decision support” (RADS) system to facilitate patient discharge while supporting many clinical and administrative needs, including: 1) providers’ compliance with asthma preventive measures, 2) creation of patient’s discharge instructions, 3) recording HMPC components for JC accreditation, and 4) creation of discharge summaries with auto-faxing mechanism to primary care providers for follow-up. RADS resulted in significant increased and sustained HMPC compliance (73% vs. 89%, p<0.01) and reduced labor time (53 vs. 15 hours/week, p=0.02) compared to standard methods. Most quality improvement interventions achieve short-term goals, but long-term improvements require decision support tools that support multiple needs while minimizing resource use.
PMCID: PMC3041425  PMID: 21347038
8.  Enhancing an Existing Clinical Information System to Improve Study Recruitment and Census Gathering Efficiency 
Information technology can improve healthcare efficiency. We developed and implemented a simple and inexpensive tool, the “Automated Case Finding and Alerting System” (ACAS), using data from an existing clinical information system to facilitate identification of potentially eligible patients for clinical trials and patient encounters for billing purposes. We validated the ACAS by calculating the level of agreement in patient identification with data generated from manual identification methods. There was substantial agreement between the two methods both for clinical trial (kappa:0.84) and billing (kappa:0.97). Automated identification occurred instantaneously vs. about 2 hours/day for clinical trial and 1 hour 10 minutes/day for billing, and was inexpensive ($98.95, one time fee) compared to manual identification ($1,200/month for clinical trial and $670/month for billing). Automated identification was more efficient and cost-effective than manual identification methods. Repurposing clinical information beyond their traditional use has the potential to improve efficiency and decrease healthcare cost.
PMCID: PMC2815472  PMID: 20351902
9.  Validation of an Electronic System for Recording Medical Student Patient Encounters 
The Liaison Committee for Medical Education requires monitoring of the students’ clinical experiences. Student logs, typically used for this purpose, have a number of limitations. We used an electronic system called Patient Tracker to passively generate student encounter data. The data contained in Patient Tracker was compared to the information reported on student logs and data abstracted from the patients’ charts. Patient Tracker identified 30% more encounters than the student logs. Compared to the student logs, Patient Tracker contained a higher average number of diagnoses per encounter (2.28 vs. 1.03, p<0.01). The diagnostic data contained in Patient Tracker was also more accurate under 4 different definitions of accuracy. Only 1.3% (9/677) of diagnoses in Patient Tracker vs. 16.9% (102/601) diagnoses in the logs could not be validated in patients’ charts (p<0.01). Patient Tracker is a more effective and accurate tool for documenting student clinical encounters than the conventional student logs.
PMCID: PMC2655951  PMID: 18999155
10.  A Tool for Improving Patient Discharge Process and Hospital Communication Practices: the Patient Tracker 
Hospital bed demands sometimes exceed capacity, leading to delays in patient admissions, transfers and cancellations of surgical procedures. Effective strategies must be in place for an efficient use of existing beds. Establishing such strategies at academic hospitals poses serious challenges. We developed and implemented a web-based software application called “Patient Tracker” to manage the discharge process, minimize delays in admission and reduce surgical procedure cancellations. We also tested the effectiveness of the software on the work flow by comparing outcomes between the pre-implementation control group (2002–2003) and the post-implementation experimental group (2003–2006). Following the implementation of the software, the number of cancelled surgical procedures decreased (120 vs. 12, p<0.01). During the same period, the average number of inpatient admissions increased (5725 vs. 6120), and the median emergency department LOS decreased (247 vs. 232, p<0.01).
PMCID: PMC2655791  PMID: 18693885

Results 1-10 (10)