Category Archives: Pediatrics

Deriving Measures of High Value Pediatric Care

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A recent article titled, “How does a gastroenterologist demonstrate value?” (linked to full text) DOI: http://dx.doi.org/10.1016/j.cgh.2014.08.021 provides some insight into what is in store for gastroenterologists as the shift from fee-for-service is influenced by value care initiatives.

Key points:

  • Value = Outcome/Cost
  • Healthcare value = Health of population/Cost
  • “AGA has spent the last 7 years developing measures that focus on outcomes and population management. They are available at http://www.gastro.org/practice/quality-initiatives/performance-measures.”This website provides several measures for hepatitis C, inflammatory bowel disease, endoscopy, and others.
  • For example, endoscopy measures:Measure # 1: Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk PatientsMeasure #2: Surveillance Colonoscopy Interval for Patients with a History of Colonic Polyps- Avoidance of Inappropriate UseMeasure # 3: Comprehensive Colonoscopy Documentation

As a pediatric gastroenterologist, it is clear that more efforts will be needed for the pediatric population.  While the authors note that “financial pressures will intensify over time,” at the current time there is extremely wide variation on the use of common procedures; in fact, physicians are typically incentivized to perform procedures even in the setting of low yield.  So the first steps will be to define a high value pediatric GI practice.

Another reference with regard to value care (J Pediatr 2014; 165: 650-51) discusses how infectious disease consultations improve outcomes, can decrease costs (length of stay, complications) and improve usage of appropriate antimicrobials.  Another helpful point: “Although common, curbside consultations have been shown to be associated with inferior patient outcomes compared with official bedside consultations.”  This is often due to incomplete or inaccurate data.

Related blog posts:

Do You Really Need Both a CRP and ESR?

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An erythrocyte sedimentation rate (ESR) and a C-reactive protein (CRP) are often ordered together, but many times provide similar information.  An ESR is a measure of acute phase proteins in the plasma.  A CRP is a proinflammatory acute phase reactant “which responds to infection and trauma by activating the complement/phagocytosis components of the immune system.”

Inevitably with the two tests, there is a higher sensitivity; for example, with osteomyelitis, one study found the paired testing had a 98% sensitivity compared with a 95% sensitivity for CRP alone (not statistically significant).  However, the authors note that “concordant or discordant results also have been found to lack clinical utility.”  As a consequence, the authors decided to investigate the costs of pairing these tests.  At their 739 tertiary care hospital, the additional cost resulted in charges between $250,000-400,000 more than ordering a single test.  They extrapolate the cost to $300 million nationally.

Take-home message: If you were spending your own money &/or trying to be a good steward of someone else’s, could you justify the expense of routinely obtaining both an ESR and a CRP?

Related blog post:

What physicians can learn from fast-food restaurants and …

If a Guideline Falls in The Woods, and No One Hears It

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Two recent articles highlight how ineffective guidelines can be:

  • J Pediatr 2014; 165: 570-6.
  • J Pediatr 2014; 165: 585-91.

In the first retrospective multicenter study, the authors note that hospitals with institutional clinical practice guidelines (CPGs) for bronchiolitis did not have significant reductions in the use of tests and treatments (eg. complete blood count, chest X-ray, bronchodilator use, steroid and antibiotic use).  However, two factors, time that CPG had been in place and ready access to an online written document were associated with a reduction in tests and corticosteroids.

In the second study, a retrospective cohort study of 17,299 cases of uncomplicated pneumonia at 125 hospitals, antibiotic choices rarely coincided with recommended guidelines.  “Ampicillin or penicillin G is strongly recommended for first-line management of uncomplicated pediatric CAP [community acquired pneumonia] in the inpatient setting barring substantial high level penicillin resistance of Streptococcus pneumoniae in the community.” Yet, in this study, about 75% received a third-generation cephalosporin and 5-10% received monotherapy with a macrolide.  The former is generally unnecessary and not advantageous, whereas the latter has a lower efficacy. Less than 1% received a recommended choice.

Bottomline: These studies have obvious implications well beyond bronchiolitis and pneumonia. Experts can agree on plethora of guidelines but they are almost meaningless without efforts to get clinicians to use them.

For Pediatric GI MDs: Imaging and Anecdote in Cockayne Syndrome

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A brief article (J Pediatr 2014; 165: 416) discusses “susceptibility-weighted imaging” (SWI) for calcification in Cockayne syndrome.

SWI is a gradient-echo MRI sequence with a high sensitivity for blood, blood products, nonheme iron, and calcifications.

The reason why I highlighted this reference relates to a personal experience.  Several years ago I had a patient (about 8 years old at the time) who had mild GI symptoms along with very poor growth.  He had some mild neurologic features but extensive testing by several neurologists and a few well-qualified geneticists did not yield an answer.  Due to my concerns about his poor growth, I convinced the family to have their son admitted to our hospital before considering another trip out-of-town for further testing. As part of his evaluation, I reordered an MRI of his brain.  One of our radiologists (who is brilliant) called me up asking for clinical information and stated specifically that she was concerned about Cockayne syndrome.  After she mentioned the diagnosis, I questioned the family regarding some more specific features of Cockayne (e.g. photosensitivity).  Subsequently, genetic testing proved this child had Cockayne syndrome.

Cockayne syndrome is a rare autosomal recessive disorder that belongs to the family of damaged DNA repair disorders.  Besides photosensitivity and cachectic dwarfism, other features include neurosensory hearing loss, and progressive pigmentary retinopathy.  The physical features are quite characteristic –if you have seen a previous case!  The disease is rare enough that many experienced geneticists may not have seen a case.

Take-home message from this article: Careful MRI study of the brain, potentially with SWI, can help pinpoint the diagnosis of Cockayne syndrome.

On an unrelated matter, I wanted to thank Janet R for her note and let her know that she will be missed.

Bionic Pancreas -It Works!

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From 1974-1978, I watched “The Six Million Dollar Man.”  The premise of the show was that astronaut Steve Austin played by Lee Majors was rebuilt with bionic parts after a severe crash.  He worked for the government to stop the bad guys.

So, when I read about a “bionic” pancreas in a recent publication (NEJM 2014; 371: 313-25), I was definitely interested.  In this study, the bionic pancreas was a “fully automated, bihormonal” (administered both insulin and glucagon) device.  It consisted of an iPhone 4S and a G4 Platinum continuous glucose monitor which were connected by a custom hardware interface.  This study was feasible due to the availability of accurate continuous glucose monitoring allowing the development of a device to more precisely regulate glycemic control.

In this study, both adults (n=20) and adolescents (n=32) with type 1 diabetes were followed closely with either the bionic pancreas or a insulin pump.

Key finding: “as compared with an insulin pump, a wearable, automated, bihormonal, bionic pancreas improved mean glycemic levels.”

Bottomline: A bionic pancreas has the potential to be a significant upgrade from a standard insulin pump –patients with type 1 diabetes may no longer have to think about how to adjust their blood glucose.  While this bionic pancreas does not reach the promise of the 1970s show of ‘we can build him better than he was before,’ it does show that bionic parts and prosthetics are improving.  For those who want a video explanation –here’s a link to 3-minute video explanation from the inventor from Boston University.

Will This Change ALTE-GERD Practice?

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This blog has highlighted several publications which have shown the lack of benefit and potential harm of pharmaceutical agents for gastroesophageal reflux “disease” (GERD) in infancy (see links below). However, in current practice, proton pump inhibitors and histamine receptor antagonists are used frequently.  Now, another influential study (J Pediatr 2014; 165: 250-5) has shown the lack of GERD as a causal mechanism in acute life-threatening events (ALTEs) and demonstrated other pathophysiologic mechanisms. However, changing physicians’ practice in this regard may prove to be as difficult as avoiding overprescribing antibiotics, or convincing reluctant parents to vaccinate their children.

So what did this study show?

This study of 20 infants (10 with proven ALTE and 10 healthy controls) had pharyngoesophageal manometry.  Key findings:

  • Infants with ALTE (vs controls) had delays in restoring aerodigestive normalcy (P=.03).  This was indicated by more frequent and prolonged spontaneous respiratory events (SREs)
  • Infants with ALTE had a lower magnitude of protective upper esophageal sphincter contractile reflexes (P=.01)
  • Infants with ALTE had swallowing as the most frequent esophageal event associated with SREs (84%), a higher proportion of failed esophageal propagation (10% vs 0%, P=.02), an more frequent mixed apnea mechanisms (P=<.01) along with gasping breaths (P=.04)

The associated editorial (pg 225-26) explains some of the limitations of the study, including the fact that the patients had a mean gestational age of 28 weeks.

The authors conclusion: “In infants with ALTE, prolonged SREs are associated with ineffective esophageal motility ,,,suggestive of dysfunctional regulation of swallow-respiratory junction interactions.  Hence, treatment should not target gastroesophageal reflux, but rather the proximal aerodigestive tract.”

Take-home message: (from the editorial): “Far too many low birth weight (and term) infants are being unnecessarily treated with a variety of antireflux medications that have serious side effects and few, if any, demonstrable benefits.”

Related blog posts:

Skinnier TVs and Heavier Kids

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A recent study showed an association between having a TV in the bedroom with increased weight gain (JAMA Pediatrics 2014; 168: 427-34).  Here’s a link: Bedroom TV and obesity study. My emphasis in bold:

Design: “We conducted a random-digit prospective telephone survey that captured children and adolescents from across the United States. Participants included 6522 boys and girls aged 10 to 14 years at baseline who were surveyed via telephone about media risk factors for obesity. Weighted regressions assessed adiposity at 2- and 4-year follow-up, controlling for television and movie viewing, video-game playing, parenting, age, sex, race or ethnicity, household income, and parental educational level.”

Results: “Distributions for age, sex, race or ethnicity, and socioeconomic status were similar to census estimates for the US population. Sample weighting methods accounted for higher dropout rates among ethnic minorities and those with lower socioeconomic status. Bedroom televisions were reported by 59.1% of participants at baseline, with boys, ethnic minorities, and those of lower socioeconomic status having significantly higher rates. In multivariate analyses, having a bedroom television was associated with an excess BMI of 0.57 (95% CI, 0.31-0.82) and 0.75 (0.38-1.12) at years 2 and 4, respectively, and a BMI gain of 0.24 (0.02-0.45) from years 2 to 4.”

Conclusion: “Having a bedroom television is associated with weight gain beyond the effect of television viewing time. This association could be the result of uncaptured effects of television viewing or of disrupted sleep patterns. With the high prevalence of bedroom televisions, the effect attributable to this risk factor among US children and adolescents is excess weight of 8.7 million kg/y.”

Comment: While this study targets TV, “screen time” has now expanded to cell phones, tablets, and computers.  All of these may be detrimental to physical well-being.

Related blog posts:

 

Vaccine Safety -Put into Perspective

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For anyone concerned about vaccine safety, putting the risks into perspective may be helpful:

“The most dangerous aspect of giving your child vaccines is driving to the office to get them,” according to Paul Offit, chief of infectious disease at Children’s Hospital of Philadelphia, in Vaccine Safety Article from USA Today.

With regard to exemptions, a recent study has shown that private schools have higher vaccine exemption rates (4.25%) than public schools (1.91%) (J Pediatr 2014; 165: 129-33).  Using CDC data for 35 states (& district of Columbia), the authors noted that there were 48,931 exemptions in 2009-2010 with only 7146 for medical reasons.  For individual states, Hawaii had the highest private school exemption rate at 14.88% and Washington had the highest public school exemption rate at 6.08%.

The authors note that parents with “higher income and educational levels expressed more concerns about vaccine safety.”  However, they state that “parents who object to immunizations have been considered ‘free riders’ as they take advantage of the benefit created by children who assume any potential risk of adverse reactions.”

In a brief summary, Sarah Long, an infectious disease expert and associate editor of The Journal of Pediatrics, questions how these parents can be “so mistrustful of doctors…and yet so confident in their own musings? At the same time that they are attempting to advantage their children by attendant a private school, they are putting their children in harm’s way.”

Related blog posts:

Safety with Peripheral IVs

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Since completing my training at Cincinnati, I regularly receive a “staff bulletin.”  One item that I thought was particularly worthwhile in the June 2014 was a discussion on minimizing harm related to peripheral intravenous (PIV) access and infusions.

The Cincinnati Vascular Access Team has developed a protocol to assess PIV sites (hourly nurse checks) and has developed a list of medicines, with the idea that higher risk medications should be given via a central line. The lists that follow are based on this staff bulletin and should be useful references.

High Risk Medicines include the following:

  • acyclovir
  • amiodarone
  • caffeine citrate
  • calcium (all salt forms)
  • dextrose (>12.5%)
  • doxycycline
  • esmolol
  • mannitol (20% and 25%)
  • promethazine
  • potassium (>60 mEq/L)
  • Sodium bicarbonate
  • Sodium chloride ≥3%
  • TPN ≥950 mOsm/L
  • Vasopressors such as dopamine
  • Chemotherapy drugs

Intermediate Risk Medicines include the following:

  • Acetazolamide
  • Allopurinol
  • Amikacin
  • Amphotericin B
  • Arginine
  • Ciprofloxacin
  • Dextrose 10 to 12.5%
  • Diazepam
  • Erythromycin
  • Ganciclovir
  • Lorazepam
  • Midazolam
  • Morphine
  • Ondansetron
  • Nafcillin
  • Non-ionic Radiology contrast
  • Phenobarbital
  • Phenytoin
  • Potassium ≤60 mEq/L
  • TPN ≤950 mOsm/L
  • Vancomycin

Lower Risk for the following:

  • aminophylline
  • amphotericin B liposomal
  • ampicillin, ampicillin/sulbactam
  • cefazolin
  • cefotaxime
  • ceftazidime
  • ceftriaxone
  • cefuroxime
  • clindamycin
  • D5LR
  • dextrose <10%
  • fentanyl
  • forsphenytoin
  • furosemide
  • gentamicin
  • heparin
  • imipenem
  • IVIG
  • lactated ringer’s
  • lipids
  • magnesium sulfate
  • meropenem
  • normal saline
  • pentamidine
  • piperacillin, piperacillin/tazobactam
  • ticarcillin, ticarcillin/clavulanate
  • tobramycin

One further warning: “No intravenous infusate is ‘safe.’ Gross extravasation, even of normal saline, may result in serious harm, including compartment syndrome, ischemia, and loss of tissue or permanent loss of limb function.”

Rotavirus Vaccine: 4-year Savings One Billion Dollars and Preventing Lots of Suffering

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A report from USA Today on the success of vaccination against rotavirus (Link: Pediatrics Rotavirus Study), here’s an excerpt:

“Vaccines against a common cause of infant diarrhea have kept hundreds of thousands of children out of the hospital, saving nearly $1 billion in their first four years, a new study shows.

The study is one of three reports in today’s Pediatrics that show the far-ranging impact of childhood vaccinations. The papers are being published as the USA faces its largest number of measles cases – 334 – in two decades. Current measles outbreaks are being fueled by parents who skip vaccines or avoid them altogether, according to the Centers for Disease Control and Prevention.

The first of the new studies focuses on rotavirus, which causes severe diarrhea and dehydration. In the first four years they were available, vaccines against rotavirus prevented more than 176,000 hospitalizations, 242,000 emergency department visits, and 1.1 million doctor’s visits among children under 5, the study says. The vaccines saved an estimated $924 million during the same period, 2007 to 2011, according to the CDC study.”

While this study is not likely to change the ingrained beliefs of many who are opposed to vaccines (Parental Immunity (to Education) and Vaccine Decision …), perhaps humor will be more successful.  Here’s a terrific link from The Daily Show’s Samantha Bee: An Outbreak of Liberal Idiocy – The Daily Show – Video Clip …

Related blog post: Alan Alda (aka Hawkeye Pierce) on Communicating Science