Samir S Shah

University of Cincinnati, Cincinnati, Ohio, United States

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Publications (232)1044.26 Total impact

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    ABSTRACT: Objective: Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs. Methods: All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared. Results: Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews. Conclusions: OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
    Academic pediatrics 09/2015; 15(5):518-525. DOI:10.1016/j.acap.2014.12.005 · 2.01 Impact Factor
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    ABSTRACT: To study the comparative effectiveness of dexamethasone vs prednisone/prednisolone in children hospitalized with asthma exacerbation not requiring intensive care. This multicenter retrospective cohort study, using the Pediatric Health Information System, included children aged 4-17 years who were hospitalized with a principal diagnosis of asthma between January 1, 2007 and December 31, 2012. Children with chronic complex condition and/or initial intensive care unit (ICU) management were excluded. Propensity score matching was used to detect differences in length of stay (LOS), readmissions, ICU transfer, and cost between groups. 40 257 hospitalizations met inclusion criteria; 1166 (2.9%) received only dexamethasone. In the matched cohort (N = 1284 representing 34 hospitals), the LOS was significantly shorter in the dexamethasone group compared with the prednisone/prednisolone group. The proportion of subjects with a LOS of 3 days or more was 6.7% in the dexamethasone group and 12% in the prednisone/prednisolone group (P = .002). Differences in all-cause readmission at 7- and 30 days were not statistically significant. The dexamethasone group had lower costs of index admission ($2621 vs $2838; P < .001) and total episode of care (including readmissions) ($2624 vs $2856; P < .001) compared with the prednisone/prednisolone group. There were no clinical significant differences in ICU transfer or readmissions between groups. Dexamethasone may be considered an alternative to prednisone/prednisolone for children hospitalized with asthma exacerbation not requiring admission to intensive care. Copyright © 2015 Elsevier Inc. All rights reserved.
    The Journal of pediatrics 09/2015; 167(3):639-644.e1. DOI:10.1016/j.jpeds.2015.06.038 · 3.79 Impact Factor
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    ABSTRACT: Objective The objective was to evaluate the comparative effectiveness of beta-lactam monotherapy and beta- lactam/macrolide combination therapy in the outpatient management of children with community-acquired pneumonia (CAP).Methods This retrospective cohort study included children, ages 1–18 years, with CAP diagnosed between January 1, 2008 and January 31, 2010 during outpatient management in the Geisinger Health System. The primary exposure was receipt of beta-lactam monotherapy or beta-lactam/macrolide combination therapy. The primary outcome was treatment failure, defined as a follow-up visit within 14 days of diagnosis resulting in a change in antibiotic therapy. Logistic regression within a propensity score- restricted cohort was used to estimate the likelihood of treatment failure.ResultsOf 717 children in the analytical cohort, 570 (79.4%) received beta-lactam monotherapy and 147 (20.1%) received combination therapy. Of those who received combination therapy 58.2% of children were under 6 years of age. Treatment failure occurred in 55 (7.7%) children, including in 8.1% of monotherapy recipients, and 6.1% of combination therapy recipients. Treatment failure rates were highest in children 6–18 years receiving monotherapy (12.9%) and lowest in children 6–18 years receiving combination therapy (4.0%). Children 6–18 years of age who received combination therapy were less likely to fail treatment than those who received beta-lactam monotherapy (propensity-adjusted odds ratio, 0.51; 95% confidence interval, 0.28, 0.95).Conclusion Children 6–18 years of age who received beta- lactam/macrolide combination therapy for CAP in the outpatient setting had lower odds of treatment failure compared with those who received beta-lactam monotherapy. Pediatr Pulmonol. 2015; 9999:XX–XX. © 2015 Wiley Periodicals, Inc.
    Pediatric Pulmonology 09/2015; DOI:10.1002/ppul.23312 · 2.70 Impact Factor
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    ABSTRACT: Many studies have demonstrated a rise in computed tomography (CT) utilization in children's hospitals. However, CT utilization may be declining, perhaps due to awareness of potential hazards of pediatric ionizing radiation, such as increased risk of malignancy. The objective is to assess the trend in CT utilization in hospitalized children at freestanding children's hospitals from 2004 to 2012 and we hypothesize decreases are associated with shifts to alternate imaging modalities. Multicenter cross-sectional study of children admitted to 33 pediatric tertiary-care hospitals participating in the Pediatric Health Information System between January 1, 2004, and December 31, 2012. The rates of CT, ultrasound, and MRI for the top 10 All-Patient Refined Diagnosis Related Groups (APR-DRGs) for which CT was performed in 2004 were determined by billing data. Rates of each imaging modality for those top 10 APR-DRGs were followed through the study period. Odds ratios of imaging were adjusted for demographics and illness severity. For all included APR-DRGs except ventricular shunt procedures and nonbacterial gastroenteritis, the number of children imaged with any modality increased. CT utilization decreased for all APR-DRGs (P values < .001). For each of the APR-DRGs except seizure and infections of upper respiratory tract, the decrease in CT was associated with a significant rise in an alternative imaging modality (P values ≤ .005). For the 10 most common APR-DRGs for which children received CT in 2004, a decrease in CT utilization was found in 2012. Alternative imaging modalities for 8 of the diagnoses were used. Copyright © 2015 by the American Academy of Pediatrics.
    PEDIATRICS 08/2015; 136(3). DOI:10.1542/peds.2015-0995 · 5.47 Impact Factor
  • PEDIATRICS 08/2015; 136(2):e549-e550. DOI:10.1542/peds.2015-1549B · 5.47 Impact Factor
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    ABSTRACT: Community-acquired pneumonia (CAP) is a common and expensive cause of hospitalization among US children, many of whom receive a codiagnosis of acute asthma. The objective of this study was to describe demographic characteristics, cost, length of stay (LOS), and adherence to clinical guidelines among these groups and to compare health care utilization and guideline adherence between them. This was a multicenter retrospective cohort study using data from the Pediatric Health Information System. Children aged 2 to 18 who were hospitalized with uncomplicated CAP from July 1, 2007, to June 30, 2012 were included. Demographics, LOS, total standardized cost, and clinical guideline adherence were compared between patients with CAP only and CAP plus acute asthma. Among the 25 124 admissions, 57% were diagnosed with CAP only; 43% had a codiagnosis of acute asthma. The geometric mean for standardized cost was $4830; for LOS, it was 2.01 days. Eighty-four percent of patients had chest radiographs; CAP+acute asthma patients were less likely to have a blood culture performed (36% vs 62%, respectively) and more likely not to have a complete blood count performed (49% vs 27%, respectively). Greater guideline adherence was associated with higher cost at the patient-level but lower average cost per hospitalization at the hospital level. CAP+acute asthma patients had higher relative costs (11.8%) and LOS (5.6%) within hospitals and had more cost variation across hospitals, compared with patients with CAP only. A codiagnosis of acute asthma is common for children with CAP. This could be from misdiagnosis or co-occurrence. Diagnostic and/or management variability appears to be greater in patients with CAP+asthma, which may increase resource utilization and LOS for these patients. Copyright © 2015 by the American Academy of Pediatrics.
    Hospital Pediatrics 08/2015; 5(8):415-422. DOI:10.1542/hpeds.2015-0007
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    ABSTRACT: BACKGROUND Administrative data can be used to determine optimal management of febrile infants and aid clinical practice guideline development.OBJECTIVE Determine the most accurate International Classification of Diseases, Ninth Revision (ICD-9) diagnosis coding strategies for identification of febrile infants.DESIGNRetrospective cross-sectional study.SETTINGEight emergency departments in the Pediatric Health Information System.PATIENTSInfants aged <90 days evaluated between July 1, 2012 and June 30, 2013 were randomly selected for medical record review from 1 of 4 ICD-9 diagnosis code groups: (1) discharge diagnosis of fever, (2) admission diagnosis of fever without discharge diagnosis of fever, (3) discharge diagnosis of serious infection without diagnosis of fever, and (4) no diagnosis of fever or serious infection.EXPOSUREThe ICD-9 diagnosis code groups were compared in 4 case-identification algorithms to a reference standard of fever ≥100.4°F documented in the medical record.MEASUREMENTSAlgorithm predictive accuracy was measured using sensitivity, specificity, and negative and positive predictive values.RESULTSAmong 1790 medical records reviewed, 766 (42.8%) infants had fever. Discharge diagnosis of fever demonstrated high specificity (98.2%, 95% confidence interval [CI]: 97.8-98.6) but low sensitivity (53.2%, 95% CI: 50.0-56.4). A case-identification algorithm of admission or discharge diagnosis of fever exhibited higher sensitivity (71.1%, 95% CI: 68.2-74.0), similar specificity (97.7%, 95% CI: 97.3-98.1), and the highest positive predictive value (86.9%, 95% CI: 84.5-89.3).CONCLUSIONSA case-identification strategy that includes admission or discharge diagnosis of fever should be considered for febrile infant studies using administrative data, though underclassification of patients is a potential limitation. Journal of Hospital Medicine 2015;. © 2015 Society of Hospital Medicine
    Journal of Hospital Medicine 08/2015; DOI:10.1002/jhm.2441 · 2.30 Impact Factor
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    ABSTRACT: There is an increasing focus on optimizing health care quality and reducing costs. The care of children undergoing heart surgery requires significant investment of resources, and it remains unclear how costs of care relate to quality. We evaluated this relationship across a multicenter cohort. Clinical data from The Society of Thoracic Surgeons Database were merged with cost data from the Pediatric Health Information Systems Database for children undergoing heart surgery (2006 to 2010). Hospital-level costs were modeled using Bayesian hierarchical methods adjusting for case-mix, and hospitals were categorized into cost tertiles. The primary quality metric evaluated was in-hospital mortality. Overall, 27 hospitals (30,670 patients) were included. Median adjusted cost per case was $82,360 and varied fivefold across hospitals, while median adjusted mortality was 3.4% and ranged from 2.4% to 5.0% across hospitals. Overall, hospitals in the lowest cost tertile had significantly lower adjusted mortality rates compared with the middle and high cost tertiles (2.5% vs 3.8% and 3.5%, respectively, both p < 0.001). When assessed at the individual hospital level, most (75%) but not all hospitals in the lowest cost tertile were also in the lowest mortality tertile. Similar relationships were seen across the spectrum of surgical complexity. Lower cost hospitals also had shorter length of stay and trends toward fewer major complications. Lowest cost hospitals generally deliver the highest quality care for children undergoing heart surgery, although there is some variation in this relationship. This information is important in the design of initiatives aiming to optimize health care value in this population. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of thoracic surgery 07/2015; DOI:10.1016/j.athoracsur.2015.04.139 · 3.85 Impact Factor
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    ABSTRACT: To investigate the association of the 2011 American Academy of Otolaryngology Head and Neck Surgery guidelines with perioperative care processes and outcomes in children undergoing tonsillectomy. We conducted a retrospective cohort study of otherwise healthy children undergoing tonsillectomy between January 2009 and January 2013 at 29 US children's hospitals participating in the Pediatric Health Information System. We measured evidence-based processes suggested by the guidelines (perioperative dexamethasone and no antibiotic use) and outcomes (30-day tonsillectomy complication-related revisits). We analyzed rates aggregated over the preguideline and postguideline periods and then by month over time by using interrupted time series. Of 111 813 children who underwent tonsillectomy, 54 043 and 57 770 did so in the preguideline and postguideline periods, respectively. Dexamethasone use increased from 74.6% to 77.4% (P < .001) in the preguideline to postguideline period, as did its rate of change in use (percentage change per month, -0.02% to 0.29%; P < .001). Antibiotic use decreased from 34.7% to 21.8% (P < .001), as did its rate of change in use (percentage change per month, -0.17% to -0.56%; P < .001). Revisits for bleeding remained stable; however, total revisits to the hospital for tonsillectomy complications increased from 8.2% to 9.0% (P < .001) because of an increase in revisits for pain. Hospital-level results were similar. The guidelines were associated with some improvement in evidence-based perioperative care processes but no improvement in outcomes. Dexamethasone use increased slightly, and antibiotic use decreased substantially. Revisits for tonsillectomy-related complications increased modestly over time because of revisits for pain. Copyright © 2015 by the American Academy of Pediatrics.
    PEDIATRICS 06/2015; 136(1). DOI:10.1542/peds.2015-0127 · 5.47 Impact Factor
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    ABSTRACT: The highest incidence of childhood acute lower respiratory tract infection (ALRI) is in low- and middle-income countries. Few studies examined whether detection of respiratory viruses predicts ALRI outcomes in these settings. We conducted prospective cohort and case-control studies of children 1-23 months of age in Botswana. Cases met clinical criteria for pneumonia and were recruited within six hours of presentation to a referral hospital. Controls were children without pneumonia matched to cases by primary care clinic and date of enrollment. Nasopharyngeal specimens were tested for respiratory viruses using polymerase chain reaction. We compared detection rates of specific viruses in matched case-control pairs. We examined the effect of respiratory syncytial virus (RSV) and other respiratory viruses on pneumonia outcomes. Between April 2012 and August 2014, we enrolled 310 cases, of which 133 had matched controls. Median ages of cases and controls were 6.1 and 6.4 months, respectively. One or more viruses were detected from 75% of cases and 34% of controls. RSV and human metapneumovirus were more frequent among cases than controls, but only enterovirus/rhinovirus was detected from asymptomatic controls. Compared with non-RSV viruses, RSV was associated with an increased risk of treatment failure at 48 hours [risk ratio (RR): 1.85; 95% confidence interval (CI): 1.20, 2.84], more days of respiratory support [mean difference (MD): 1.26 days; 95% CI: 0.30, 2.22 days], and longer duration of hospitalization [MD: 1.35 days; 95% CI: 0.20, 2.50 days], but lower in-hospital mortality [RR: 0.09; 95% CI: 0.01, 0.80] in children with pneumonia. Respiratory viruses were detected from most children hospitalized with ALRI in Botswana, but only RSV and human metapneumovirus were more frequent than among children without ALRI. Detection of RSV from children with ALRI predicted a protracted illness course but lower mortality compared with non-RSV viruses.
    PLoS ONE 05/2015; 10(5):e0126593. DOI:10.1371/journal.pone.0126593 · 3.23 Impact Factor
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    ABSTRACT: We examined the association between baseline peripheral white blood cell count (WBC) and C-reactive protein (CRP) values with outcomes among 153 children hospitalized with pneumonia. In multivariable analyses, CRP, but not WBC count, was significantly associated with both fever duration and hospital length of stay. For every 1mg/dL increase in CRP, length of stay increased by 1 hour.
    The Pediatric Infectious Disease Journal 05/2015; 34(7). DOI:10.1097/INF.0000000000000724 · 2.72 Impact Factor
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    ABSTRACT: Most children diagnosed with community-acquired pneumonia (CAP) are treated in the outpatient setting. The objective of this study was to determine the comparative clinical effectiveness of beta-lactam monotherapy and macrolide monotherapy in this population. Children, 1-18 years old, with a clinical diagnosis of CAP at an outpatient practice affiliated (n=71) with Geisinger Health System during January 1, 2008 to January 31, 2010 were eligible. The primary exposure was receipt of beta-lactam or macrolide monotherapy. The primary outcome was treatment failure defined as change in antibiotic prescription within 14 days of the initial pneumonia diagnosis. Propensity scores were used to determine the likelihood of receiving macrolide monotherapy. Treatment groups were matched 1:1, based on propensity score, age group and asthma status. Multivariable conditional logistic regression models estimated the association between macrolide monotherapy and treatment failures. Of 1,999 children with CAP, 1,164 were matched. In the matched cohorts, 24% of children had asthma. Patients who received macrolide monotherapy had no statistical difference in treatment failure regardless of age when compared with patients who received beta-lactam monotherapy. Our findings suggest that children diagnosed with CAP in the outpatient setting and treated with beta-lactam or macrolide monotherapy have the same likelihood to fail treatment regardless of age.
    The Pediatric Infectious Disease Journal 04/2015; Publish Ahead of Print(8). DOI:10.1097/INF.0000000000000740 · 2.72 Impact Factor
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    ABSTRACT: A national evidence-based guideline for the management of community-acquired pneumonia (CAP) in children recommends blood cultures for patients admitted with moderate to severe illness. Our primary aim was to increase ordering of blood cultures for children hospitalized with CAP from 53% to 90% in 6 months. The secondary aim was to evaluate the effect of obtaining blood cultures on length of stay (LOS). At a tertiary children's hospital, interventions to increase blood cultures focused on 3 key drivers and were tested separately in the emergency department and inpatient units by using multiple plan-do-study-act cycles. The impact of the interventions was tracked over time on run charts. The association of ordering blood cultures and LOS was estimated by using linear regression models. Within 6 months, the percentage of patients admitted with CAP who had blood cultures ordered increased from 53% to 100%. This change has been sustained for 12 months. Overall, 239 (79%) of the 303 included patients had a blood culture ordered; of these, 6 (2.5%) were positive. Patients who had a blood culture did not have an increased LOS compared with those without a blood culture. Quality improvement methods were used to increase adherence to evidence-based national guidelines for performing blood cultures on children hospitalized with CAP; LOS did not increase. These results support obtaining blood cultures on all patients admitted with CAP without negative effects on LOS in a setting with a reliably low false-positive blood culture rate. Copyright © 2015 by the American Academy of Pediatrics.
    Pediatrics 03/2015; 135(4). DOI:10.1542/peds.2014-2077 · 5.47 Impact Factor
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    ABSTRACT: Pediatric observation units (OUs) have demonstrated reductions in lengths of stay (LOS) and costs of care. Hospital-level outcomes across all observation-status stays have not been evaluated in relation to the presence of a dedicated OU in the hospital. To compare observation-status stay outcomes in hospitals with and without a dedicated OU. Cross-sectional analysis of hospital administrative data. Observation-status stay outcomes were compared in hospitals with and without a dedicated OU across 4 categories: (1) LOS, (2) standardized costs, (3) conversion to inpatient status, and (4) return care. Observation-status stays in 31 free-standing children's hospitals contributing observation patient data to the Pediatric Health Information System database, 2011. Fifty-one percent of the 136,239 observation-status stays in 2011 occurred in 14 hospitals with a dedicated OU; the remainder were in 17 hospitals without. The percentage of observation-status same-day discharges was higher in hospitals with a dedicated OU compared with hospitals without (23.8 vs 22.1, P < 0.001), but risk-adjusted LOS in hours and total standardized costs were similar. Conversion to inpatient status was higher in hospitals with a dedicated OU (11.06%) compared with hospitals without (9.63%, P < 0.01). Adjusted odds of return visits and readmissions were comparable. The presence of a dedicated OU appears to have an influence on same-day and morning discharges across all observation-status stays without impacting other hospital-level outcomes. Inclusion of location of care (eg, dedicated OU, inpatient unit, emergency department) in hospital administrative datasets would allow for more meaningful comparisons of models of hospital care. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine. © 2015 Society of Hospital Medicine.
    Journal of Hospital Medicine 03/2015; 10(6). DOI:10.1002/jhm.2339 · 2.30 Impact Factor
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    ABSTRACT: To describe utilization of 3% hypertonic saline (HTS) in hospitalized infants and to evaluate the association between HTS use and length of stay (LOS) in a real-world setting. This multicenter retrospective cohort study included infants ≤12 months hospitalized with bronchiolitis between October 2008 and September 2011 using the Pediatric Health Information System. HTS use was categorized as trial, rescue, daily, or sporadic. Differences in LOS were compared after matching daily HTS recipients and nonrecipients on propensity score. There were 63 337 hospitalizations for bronchiolitis. HTS was used in 24 of 42 hospitals and 2.9% of all hospitalizations. HTS use increased from 0.4% of visits in 2008 to 9.2% of visits in 2011. There was substantial variation in HTS use across hospitals (range 0.1%-32.6%). When used, HTS was given daily during 60.6% of hospitalizations, sporadically in 10.4%, as a trial in 11.3%, and as a rescue in 17.7%. The propensity score-matched analysis of daily HTS recipients (n = 953) vs nonrecipients (n = 953) showed no difference in mean LOS (HTS 2.3 days vs nonrecipients 2.5 days; β-coefficient -0.04; 95% CI -0.15, 0.07; P = .5) or odds of staying longer than 1, 2, or 3 days. Daily HTS recipients had a 33% decreased odds of staying in the hospital >4 days compared with nonrecipients (OR 0.67; 95% CI 0.47, 0.97; P = .03). Variation in HTS use and the lack of association between HTS and mean LOS demonstrates the need for further research to standardize HTS use and better define the infants for whom HTS will be most beneficial. Copyright © 2015 Elsevier Inc. All rights reserved.
    Journal of Pediatrics 03/2015; 166(5). DOI:10.1016/j.jpeds.2015.01.045 · 3.79 Impact Factor
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    ABSTRACT: Mother-to-child transmission of HIV can be prevented by prenatal and peripartum interventions. We sought to determine the prevalence of vertical HIV transmission in an urban cohort of HIV-exposed infants and describe cases of vertical HIV infection presenting during and after the neonatal period. This retrospective cohort study included HIV-exposed infants born between July 1, 2003, and June 30, 2012, who received care at an urban referral site. There were 516 infants with HIV exposure known by the time of delivery; 9 of these infants (1.7%; 95% confidence interval: 0.8%-3.3%) were HIV infected. The HIV infection rate was 0.7% for those receiving prenatal antiretroviral (ARV) therapy and 9.3% for those receiving only intrapartum and/or postnatal ARV therapy. Among those diagnosed with HIV at delivery, 46% received no prenatal care. Our data suggest that strategies to eliminate infant HIV infections ought to include ensuring better access to prenatal care, HIV testing, and ARV therapy initiation during pregnancy. Copyright © 2015 by the American Academy of Pediatrics.
    Hospital Pediatrics 02/2015; 5(2):92-5. DOI:10.1542/hpeds.2014-0102
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    ABSTRACT: BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs.OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants.DESIGNRetrospective cross-sectional study in 2013.SETTINGThirty-three hospitals in the Pediatric Health Information System.PATIENTSInfants aged ≤56 days with a diagnosis of fever.EXPOSURESThe presence and content of ED-based febrile infant CPGs assessed by electronic survey.MEASUREMENTSUsing generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs.RESULTSWe included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs.CONCLUSIONSCPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine
    Journal of Hospital Medicine 02/2015; 10(6). DOI:10.1002/jhm.2329 · 2.30 Impact Factor
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    ABSTRACT: In congenital heart surgery, hospital performance has historically been assessed using widely available administrative data sets. Recent studies have demonstrated inaccuracies in case ascertainment (coding and inclusion of eligible cases) in administrative versus clinical registry data; however, it is unclear whether this impacts assessment of performance on a hospital level. Merged data from The Society of Thoracic Surgeons (STS) database (clinical registry) and the Pediatric Health Information Systems (PHIS) database (administrative data set) for 46,056 children undergoing cardiac operations (2006-2010) were used to evaluate in-hospital mortality for 33 hospitals based on their administrative versus registry data. Standard methods to identify/classify cases were used: Risk Adjustment in Congenital Heart Surgery, version 1 (RACHS-1) in the administrative data and STS-European Association for Cardiothoracic Surgery (STAT) methodology in the registry. Median hospital surgical volume based on the registry data was 269 cases per year; mortality was 2.9%. Hospital volumes and mortality rates based on the administrative data were on average 10.7% and 4.7% lower, respectively, although this varied widely across hospitals. Hospital rankings for mortality based on the administrative versus registry data differed by 5 or more rank positions for 24% of hospitals, with a change in mortality tertile classification (high, middle, or low mortality) for 18% and a change in statistical outlier classification for 12%. Higher volume/complexity hospitals were most impacted. Agency for Healthcare Quality and Research (AHRQ) methods in the administrative data yielded similar results. Inaccuracies in case ascertainment in administrative versus clinical registry data can lead to important differences in assessment of hospital mortality rates for congenital heart surgery. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of Thoracic Surgery 01/2015; 99(3). DOI:10.1016/j.athoracsur.2014.10.069 · 3.85 Impact Factor
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    ABSTRACT: Postdischarge treatment of acute osteomyelitis in children requires weeks of antibiotic therapy, which can be administered orally or intravenously via a peripherally inserted central catheter (PICC). The catheters carry a risk for serious complications, but limited evidence exists on the effectiveness of oral therapy. To compare the effectiveness and adverse outcomes of postdischarge antibiotic therapy administered via the PICC or the oral route. We performed a retrospective cohort study comparing PICC and oral therapy for the treatment of acute osteomyelitis. Among children hospitalized from January 1, 2009, through December 31, 2012, at 36 participating children's hospitals, we used discharge codes to identify potentially eligible participants. Results of medical record review confirmed eligibility and defined treatment group allocation and study outcomes. We used within- and across-hospital propensity score-based full matching to adjust for confounding by indication. Postdischarge administration of antibiotics via the PICC or the oral route. The primary outcome was treatment failure. Secondary outcomes included adverse drug reaction, PICC line complication, and a composite of all 3 end points. Among 2060 children and adolescents (hereinafter referred to as children) with osteomyelitis, 1005 received oral antibiotics at discharge, whereas 1055 received PICC-administered antibiotics. The proportion of children treated via the PICC route varied across hospitals from 0 to 100%. In the across-hospital (risk difference, 0.3% [95% CI, -0.1% to 2.5%]) and within-hospital (risk difference, 0.6% [95% CI, -0.2% to 3.0%]) matched analyses, children treated with antibiotics via the oral route (reference group) did not experience more treatment failures than those treated with antibiotics via the PICC route. Rates of adverse drug reaction were low (<4% in both groups) but slightly greater in the PICC group in across-hospital (risk difference, 1.7% [95% CI, 0.1%-3.3%]) and within-hospital (risk difference, 2.1% [95% CI, 0.3%-3.8%]) matched analyses. Among the children in the PICC group, 158 (15.0%) had a PICC complication that required an emergency department visit (n = 96), a rehospitalization (n = 38), or both (n = 24). As a result, the PICC group had a much higher risk of requiring a return visit to the emergency department or for hospitalization for any adverse outcome in across-hospital (risk difference, 14.6% [95% CI, 11.3%-17.9%]) and within-hospital (risk difference, 14.0% [95% CI, 10.5%-17.6%]) matched analyses. Given the magnitude and seriousness of PICC complications, clinicians should reconsider the practice of treating otherwise healthy children with acute osteomyelitis with prolonged intravenous antibiotics after hospital discharge when an equally effective oral alternative exists.
    JAMA Pediatrics 12/2014; 169(2). DOI:10.1001/jamapediatrics.2014.2822 · 5.73 Impact Factor
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    ABSTRACT: Single-center evaluations of pediatric antimicrobial stewardship programs (ASPs) suggest that ASPs are effective in reducing and improving antibiotic prescribing, but studies are limited. Our objective was to compare antibiotic prescribing rates in a group of pediatric hospitals with formalized ASPs (ASP+) to a group of concurrent control hospitals without formalized stewardship programs (ASP-). We evaluated the impact of ASPs on antibiotic prescribing over time measured by days of therapy/1000 patient-days in a group of 31 freestanding children's hospitals (9 ASP+, 22 ASP-). We compared differences in average antibiotic use for all ASP+ and ASP- hospitals from 2004 to 2012 before and after release of 2007 Infectious Diseases Society of America guidelines for developing ASPs. Antibiotic use was compared for both all antibacterials and for a select subset (vancomycin, carbapenems, linezolid). For each ASP+ hospital, we determined differences in the average monthly changes in antibiotic use before and after the program was started by using interrupted time series via dynamic regression. In aggregate, as compared with those years preceding the guidelines, there was a larger decline in average antibiotic use in ASP+ hospitals than in ASP- hospitals from 2007 to 2012, the years after the release of Infectious Diseases Society of America guidelines (11% vs 8%, P = .04). When examined individually, relative to preimplementation trends, 8 of 9 ASP+ hospitals revealed declines in antibiotic use, with an average monthly decline in days of therapy/1000 patient-days of 5.7%. For the select subset of antibiotics, the average monthly decline was 8.2%. Formalized ASPs in children's hospitals are effective in reducing antibiotic prescribing. Copyright © 2015 by the American Academy of Pediatrics.
    Pediatrics 12/2014; 135(1). DOI:10.1542/peds.2014-2579 · 5.47 Impact Factor

Publication Stats

3k Citations
1,044.26 Total Impact Points


  • 2012–2015
    • University of Cincinnati
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      Cincinnati, Ohio, United States
    • University of Rochester
      • Department of Pediatrics
      Rochester, New York, United States
  • 2011–2015
    • Cincinnati Children's Hospital Medical Center
      • • Department of Pediatrics
      • • Division of Infectious Diseases
      Cincinnati, Ohio, United States
    • Jefferson College
      Хиллсборо, Missouri, United States
  • 2002–2013
    • The Children's Hospital of Philadelphia
      • • Division of Infectious Diseases
      • • Division of General Pediatrics
      • • Department of Pediatrics
      Philadelphia, Pennsylvania, United States
  • 2008–2011
    • William Penn University
      Filadelfia, Pennsylvania, United States
    • University of Washington Seattle
      • Department of Pediatrics
      Seattle, Washington, United States
  • 2010
    • Children's National Medical Center
      Washington, Washington, D.C., United States
  • 2007
    • Columbia University
      New York, New York, United States