Rajendu Srivastava

University of Utah, Salt Lake City, Utah, United States

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Publications (81)355.92 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: Our objective was to determine the extent of testing and costs solely related to diagnosis (the diagnostic odyssey) in a cohort of children with inherited leukodystrophies. We determined all inpatient and outpatient laboratory testing, including brain MRIs obtained for the purpose of diagnosis, over an 8-year time period in a retrospective population cohort of children with inherited leukodystrophies. Costs were determined from an activity-based cost accounting system and were standardized to 2013 constant US dollars. Each patient had on average 20 tests (range 2-42 tests), with costs of $4,200 (range $357-$15,611). Diagnostic yield plateaued after 25 tests, and costs increased significantly after 32 tests. Fifty-three percent of patients were diagnosed in 20 or fewer tests, compared with 17% if more than 20 tests were performed. Our findings provide details on the amount and costs of testing in children who often undergo a diagnostic odyssey. Our results suggest that diagnostic testing is a relatively modest contributor to the overall health care costs in patients with leukodystrophy, and offer insights into the diagnostic odyssey of children with neurologic impairment. © 2015 American Academy of Neurology.
    Neurology 08/2015; DOI:10.1212/WNL.0000000000001974 · 8.29 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
  • Melanie Duval · Jacob Wilkes · Kent Korgenski · Rajendu Srivastava · Jeremy Meier
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    ABSTRACT: To review the causes, costs, and risk factors for unplanned return visits and readmissions after pediatric adenotonsillectomy (T&A). Review of administrative database of outpatient adenotonsillectomy performed at any facility within a vertically integrated health care system in the Intermountain West on children age 1-18 years old between 1998 and 2012. Data reviewed included demographic variables, diagnosis associated with return visit and costs associated with return visits. Data from 39,906 children aged 1-18 years old were reviewed. A total of 2499 (6.3%) children had unplanned return visits. The most common reasons for return visits were bleeding (2.3%), dehydration, (2.3%) and throat pain (1.2%). After multivariate analysis, the main risk factors for any type of return visits were Medicaid insurance (OR=1.64 95% CI 1.47-1.84), Hispanic race (OR=1.36 95% CI 1.13-1.64), and increased severity of illness (SOI) (OR=11.29 95% CI 2.69-47.4 for SOI=3). The only factor associated with increased odds of requiring an inpatient admission on return visit was length of time spent in PACU (p<0.001). A linear relationship was also observed between the child's age and the risk of post-tonsillectomy hemorrhage. Children with increased severity of illness, those insured with Medicaid, and children of Hispanic ethnicity should be targeted with increased education and interventions in order to reduce unplanned visits after T&A. Further studies on post-tonsillectomy complications should include evaluating the effect of surgical technique and post-operative pain management on all complications and not solely post-tonsillectomy hemorrhage. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    International journal of pediatric otorhinolaryngology 07/2015; 79(10). DOI:10.1016/j.ijporl.2015.07.002 · 1.19 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: BACKGROUND Handoffs of patient care are a leading root cause of medical errors. Standardized techniques exist to minimize miscommunications during verbal handoffs, but studies to guide standardization of printed handoff documents are lacking.OBJECTIVE To determine whether variability exists in the content of printed handoff documents and to identify key data elements that should be uniformly included in these documents.SETTINGPediatric hospitalist services at 9 institutions in the United States and Canada.METHODS Sample handoff documents from each institution were reviewed, and structured group interviews were conducted to understand each institution's priorities for written handoffs. An expert panel reviewed all handoff documents and structured group-interview findings, and subsequently made consensus-based recommendations for data elements that were either essential or recommended, including best overall printed handoff practices.RESULTSNine sites completed structured group interviews and submitted data. We identified substantial variation in both the structure and content of printed handoff documents. Only 4 of 23 possible data elements (17%) were uniformly present in all sites' handoff documents. The expert panel recommended the following as essential for all printed handoffs: assessment of illness severity, patient summary, action items, situation awareness and contingency plans, allergies, medications, age, weight, date of admission, and patient and hospital service identifiers. Code status and several other elements were also recommended.CONCLUSIONS Wide variation exists in the content of printed handoff documents. Standardizing printed handoff documents has the potential to decrease omissions of key data during patient care transitions, which may decrease the risk of downstream medical errors. Journal of Hospital Medicine 2015. © 2015 Society of Hospital Medicine
    Journal of Hospital Medicine 05/2015; 10(8). DOI:10.1002/jhm.2380 · 2.30 Impact Factor
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    ABSTRACT: To (1) determine adherence to American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines for pediatric tonsillectomy recommending routine administration of perioperative dexamethasone and against routine antibiotic administration among surgeons and hospitals in a multihospital network and (2) evaluate the impact of adherence on the risk of complications. Case series with chart review. Multihospital network. A case series of 15,950 children aged 1 to 18 years undergoing same-day surgery adenotonsillectomy (T&A) within a multihospital network from 2008 to 2014 was reviewed to determine whether dexamethasone and/or antibiotics were given in the hospital. The frequency of dexamethasone and antibiotic administration was compared among surgeons and hospitals in the years before and after the guidelines were published. The frequency of complications was compared in adhering vs nonadhering surgeons. The study cohort included 15,950 children undergoing T&A at 19 hospitals by 74 surgeons. Of the patients before guideline publication, 98.4% (n = 7432) received dexamethasone compared with 98.9% of subjects after guideline publication (n = 8518). In total, 16.1% received antibiotics before the guidelines compared with 13.8% after. Prior to the guidelines, 27 of 74 surgeons (36%) routinely gave antibiotics. After the guidelines were published, 19 surgeons (26%) continued to give antibiotics more than 50% of the time. There was no difference in complication visits between adhering and nonadhering surgeons. Most hospitals and surgeons administered perioperative dexamethasone routinely. While the overall frequency of antibiotic administration decreased after the guidelines were published, a significant percentage of surgeons continued to give antibiotics routinely, suggesting the need for improved dissemination and implementation of guidelines to promote adherence. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.
    Otolaryngology Head and Neck Surgery 04/2015; 153(2). DOI:10.1177/0194599815582169 · 2.02 Impact Factor
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    ABSTRACT: (1) Review the reasons, timing, and costs for children presenting to the emergency department (ED) after adenotonsillectomy (T&A). Case series with chart review. Tertiary care children's hospital. A standardized activity-based hospital accounting system was used to identify 437 children from an academic pediatric otolaryngology practice presenting to the ED after T&A from 2009 to 2012. The reason for presentation, timing after surgery, and facility costs were recorded. The study cohort represented 13.3% of the 3198 patients who underwent T&A during that time period. Overall, 133 (4.2%) presented for dehydration, 106 (3.3%) presented for post-tonsillectomy hemorrhage, 65 (2.0%) for poorly controlled pain, 42 (1.3%) for fever, 29 (1.0%) for vomiting/nausea/GI discomfort, 22 (0.7%) for respiratory complications, and 12 (0.4%) for miscellaneous reasons related to the operation; 28 (0.8%) were unrelated to the T&A and excluded. Mean postoperative day at the time of ED presentation was 4.4 (95% CI, 4.1-4.7). The mean cost per patient presenting to the ED was $1420 (95% CI, $1104-$1737), the most costly subgroups being those presenting with respiratory complications ($2855; 95% CI, $1434-$4277), hemorrhage ($1502; 95% CI, $1216-$1787), and dehydration ($1372; 95% CI, $995-$1750). The least costly subgroup was acute postoperative pain ($781; 95% CI, $282-$1200). A significant portion of children present to the ED after T&A for poorly controlled pain, dehydration, or fever. The costs from these visits are significant. Accounting for these costs in the global care for pediatric T&A could assist in calculating appropriate reimbursement for bundled payments in this climate of health care reform. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.
    Otolaryngology Head and Neck Surgery 03/2015; 152(4). DOI:10.1177/0194599815572123 · 2.02 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: The Seamless Transitions and (Re)admissions Network (STARNet) met in December 2012 to synthesize ongoing hospital-to-home transition work, discuss goals, and develop a plan to centralize transition information in the future. STARNet participants consisted of experts in the field of pediatric hospital medicine quality improvement and research, and included physicians and key stakeholders from hospital groups, private payers, as well as representatives from current transition collaboratives. In this report, we (1) review the current knowledge regarding hospital-to-home transitions; (2) outline the challenges of measuring and reducing readmissions; and (3) highlight research gaps and list potential measures for transition quality. STARNet met with the support of the American Academy of Pediatrics' Quality Improvement Innovation Networks and the Section on Hospital Medicine. Copyright © 2015 by the American Academy of Pediatrics.
    Pediatrics 12/2014; 135(1). DOI:10.1542/peds.2014-1887 · 5.47 Impact Factor
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    ABSTRACT: Background: Miscommunications are a leading cause of serious medical errors. Data from multicenter studies assessing programs designed to improve handoff of information about patient care are lacking. Methods: We conducted a prospective intervention study of a resident handoff-improvement program in nine hospitals, measuring rates of medical errors, preventable adverse events, and miscommunications, as well as resident workflow. The intervention included a mnemonic to standardize oral and written handoffs, handoff and communication training, a faculty development and observation program, and a sustainability campaign. Error rates were measured through active surveillance. Handoffs were assessed by means of evaluation of printed handoff documents and audio recordings. Workflow was assessed through time-motion observations. The primary outcome had two components: medical errors and preventable adverse events. Results: In 10,740 patient admissions, the medical-error rate decreased by 23% from the preintervention period to the postintervention period (24.5 vs. 18.8 per 100 admissions, P<0.001), and the rate of preventable adverse events decreased by 30% (4.7 vs. 3.3 events per 100 admissions, P<0.001). The rate of nonpreventable adverse events did not change significantly (3.0 and 2.8 events per 100 admissions, P=0.79). Site-level analyses showed significant error reductions at six of nine sites. Across sites, significant increases were observed in the inclusion of all prespecified key elements in written documents and oral communication during handoff (nine written and five oral elements; P<0.001 for all 14 comparisons). There were no significant changes from the preintervention period to the postintervention period in the duration of oral handoffs (2.4 and 2.5 minutes per patient, respectively; P=0.55) or in resident workflow, including patient-family contact and computer time. Conclusions: Implementation of the handoff program was associated with reductions in medical errors and in preventable adverse events and with improvements in communication, without a negative effect on workflow. (Funded by the Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, and others.).
    New England Journal of Medicine 11/2014; 371(19):1803-12. DOI:10.1056/NEJMsa1405556 · 55.87 Impact Factor
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    ABSTRACT: Objective: Chronic neurological deficits are a significant complication of preterm birth. Magnesium supplementation has been suggested to have neuroprotective function in the developing brain. Our objective was to determine whether higher neonatal serum magnesium levels were associated with better long-term neurodevelopmental outcomes in very-low birth weight infants. Study Design: A retrospective cohort of 75 preterm infants (<1500 g, gestational age <27 weeks) had follow-up for the outcomes of abnormal motor exam and for epilepsy. Average total serum magnesium level in the neonate during the period of prematurity was the main independent variable assessed, tested using a Wilcoxon rank-sum test. Results: Higher average serum magnesium level was associated with a statistically significant decreased risk for abnormal motor exam (p = 0.037). A lower risk for epilepsy in the group with higher magnesium level did not reach statistical significance (p = 0.06). Conclusion: This study demonstrates a correlation between higher neonatal magnesium levels and decreased risk for long-term abnormal motor exam. Larger studies are needed to evaluate the hypothesis that higher neonatal magnesium levels can improve long-term neurodevelopmental outcomes.
    Frontiers in Pediatrics 11/2014; 2(120). DOI:10.3389/fped.2014.00120
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    ABSTRACT: Objectives/HypothesisIdentify hospital costs for same-day pediatric adenotonsillectomy (T&A) surgery, and evaluate surgeon, hospital, and patient factors influencing variation in costs, and compare relationship of costs to complications for T&A.Study DesignObservational retrospective cohort study.MethodsA multihospital network's standardized activity-based accounting system was used to determine hospital costs per T&A from 1998 to 2012. Children 1 to 18 years old who underwent same-day T&A surgery were included. Subjects with additional procedures were excluded. Mixed effects analyses were performed to identify variation in mean costs due to surgeon, hospital, and patient factors. Surgeons' mean cost/case was related to subsequent complications, defined as any unplanned visit within 21 days in the healthcare system.ResultsThe study cohort included 26,626 T&As performed by 66 surgeons at 18 hospitals. Mean cost per T&A was $1,355 ± $505. Mixed effects analysis using patient factors as fixed effects and surgeon and hospital as a random effect identified significant variation in mean costs per surgeon, with 95% of surgeons having a mean cost/case between 67% and 150% of the overall mean (range, $874–$2,232/case). Similar variability was found among hospitals, with 95% of the facilities having mean costs between 64% to 156% of the mean (range, $1,029–$2,385/case). Severity of illness and several other patient factors exhibited small but statistically significant associations with cost. Surgeons' mean cost/case was moderately associated with an increased complication rate.Conclusions Significant variation in same-day pediatric T&A surgery costs exists among different surgeons and hospitals within a multihospital network. Reducing variation in costs while maintaining outcomes may improve healthcare value and eliminate waste.Level of Evidence4. Laryngoscope, 2014
    The Laryngoscope 10/2014; 125(5). DOI:10.1002/lary.24981 · 2.14 Impact Factor
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    ABSTRACT: Patient handoffs are a key source of communication failures and adverse events in hospitals. Despite Accreditation Council for Graduate Medical Education requirements for residency training programs to provide formal handoff skills training and to monitor handoffs, well-established curricula and validated skills assessment tools are lacking. Developing a handoff curriculum is challenging because of the need for standardized processes and faculty development, cultural resistance to change, and diverse institution- and unit-level factors. In this article, the authors apply a logic model to describe the process they used from June 2010 to February 2014 to develop, implement, and disseminate an innovative, comprehensive handoff curriculum in pediatric residency training programs as a fundamental component of the multicenter Initiative for Innovation in Pediatric Education-Pediatric Research in Inpatient Settings Accelerating Safe Sign-outs (I-PASS) Study. They describe resources, activities, and outputs, and report preliminary learner outcomes using data from resident and faculty evaluations of the I-PASS Handoff Curriculum: 96% of residents and 97% of faculty agreed or strongly agreed that the curriculum promoted acquisition of relevant skills for patient care activities. They also share lessons learned that could be of value to others seeking to adopt a structured handoff curriculum or to develop large-scale curricular innovations that involve redesigning firmly established processes. These lessons include the importance of approaching curricular implementation as a transformational change effort, assembling a diverse team of junior and senior faculty to provide opportunities for mentoring and professional development, and linking the educational intervention with the direct measurement of patient outcomes.
    Academic medicine: journal of the Association of American Medical Colleges 06/2014; 89(6):876-84. DOI:10.1097/ACM.0000000000000264 · 2.93 Impact Factor
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    ABSTRACT: BACKGROUND Guidelines help inform standardization of care for quality improvement (QI). The Pediatric Research in Inpatient Settings network published a prioritization list of inpatient conditions with high prevalence, cost, and variation in resource utilization across children's hospitals. The methodological quality of guidelines for priority conditions is unknown.OBJECTIVE To rate the methodological quality of national guidelines for 20 priority pediatric inpatient conditions.DESIGNWe searched sources including PubMed for national guidelines published from 2002 to 2012. Guidelines specific to 1 organism, test or treatment, or institution were excluded. Guidelines were rated by 2 raters using a validated tool (Appraisal of Guidelines for Research and Evaluation) with an overall rating on a 7-point scale (7 = the highest). Inter-rater reliability was measured with a weighted kappa coefficient.RESULTSSeventeen guidelines met inclusion criteria for 13 conditions; 7 conditions yielded no relevant national guidelines. The highest methodological-quality guidelines were for asthma, tonsillectomy, and bronchiolitis (mean overall rating 7, 6.5, and 6.5, respectively); the lowest were for sickle cell disease (2 guidelines) and dental caries (mean overall rating 4, 3.5, and 3, respectively). The overall weighted kappa was 0.83 (95% confidence interval 0.78–0.87).CONCLUSIONS We identified a group of moderate to high methodological-quality national guidelines for priority pediatric inpatient conditions. Hospitals should consider these guidelines to inform QI initiatives. Journal of Hospital Medicine 2014. © 2014 Society of Hospital Medicine
    Journal of Hospital Medicine 06/2014; 9(6). DOI:10.1002/jhm.2187 · 2.30 Impact Factor
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    ABSTRACT: Children with inherited leukodystrophies have high hospitalization rates, often associated with infection. We studied whether potentially modifiable risk factors (preexisting indwelling central intravenous access, urinary catheter, hardware, or mechanical ventilation; and influenza vaccine) were associated with infection-related hospitalization in children with leukodystrophy. Central intravenous access was associated with sepsis (odds ratio [OR] 9.8); urinary catheter was associated with urinary tract infections (OR 9.0); lack of seasonal vaccination was associated with influenza (OR 6.4); and mechanical ventilation was associated with pneumonia (OR 2.7). We conclude that potentially modifiable risk factors are significantly associated with infection and hospitalization in children with leukodystrophies.
    05/2014; 1(5). DOI:10.1002/acn3.61
  • Hospital Pediatrics 03/2014; 4(2):69-77. DOI:10.1542/hpeds.2013-0019
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    ABSTRACT: To (1) identify the major expenses for same-day adenotonsillectomy (T&A) and the costs for postoperative complication encounters in a children's hospital and (2) compare differences for variations in costs by surgeon. Observational cohort study. Tertiary children's hospital. A standardized activity-based hospital accounting system was used to determine total hospital costs per encounter (not including professional fees for surgeons or anesthetists) for T&A cases at a tertiary children's hospital from 2007 to 2012. Hospital costs were subdivided into categories, including operating room (OR), OR supplies, postanesthesia care unit (PACU), same-day services (SDS), anesthesia, pharmacy, and other. Costs for postoperative complication encounters were included to identify a mean total cost per case per surgeon. The study cohort included 4824 T&As performed by 14 different surgeons. The mean cost per T&A was $1506 (95% confidence interval, $1492-$1519, with a range of $1156-$1828 for the lowest and highest cost per case per surgeon; P < .01). Including the cost for postoperative complications, the mean cost increased to $1599 ($1570-$1629). The largest cost categories included OR (31.9%), SDS (28.1%), and OR supplies (15.6%). A large portion of T&A expenses are due to OR and supply costs. Significant differences in costs between surgeons for outpatient T&A were identified. Studies to understand the reasons for this variation and the impact on outcomes are needed. If this variation does not affect patient outcomes, then reducing this variation may improve health care value by limiting waste.
    Otolaryngology Head and Neck Surgery 02/2014; 150(5). DOI:10.1177/0194599814522758 · 2.02 Impact Factor
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    ABSTRACT: To determine whether dexamethasone use in children undergoing tonsillectomy is associated with increased risk of postoperative bleeding. Retrospective cohort study using a multihospital administrative database. Thirty-six US children's hospitals. Children undergoing same-day tonsillectomy between the years 2004 and 2010. We used discrete time failure models to estimate the daily hazards of revisits for bleeding (emergency department or hospital admission) up to 30 days after surgery as a function of dexamethasone use. Revisits were standardized for patient characteristics, antibiotic use, year of surgery, and hospital. Of 139,715 children who underwent same-day tonsillectomy, 97,242 (69.6%) received dexamethasone and 4182 (3.0%) had a 30-day revisit for bleeding. The 30-day cumulative standardized risk of revisits for bleeding was greater with dexamethasone use (3.11% vs 2.71%; standardized difference 0.40% [95% confidence interval, 0.13%-0.67%]; P = .003), and the increased risk was observed across all age strata. Dexamethasone use was associated with a higher standardized rate of revisits for bleeding in the postdischarge time periods of days 1 through 5 but not during the peak period for secondary bleeding, days 6 and 7. In a real-world practice setting, dexamethasone use was associated with a small absolute increased risk of revisits for bleeding. However, the upper bound of this risk increase does not cross published thresholds for a minimal clinically important difference. Given the benefits of dexamethasone in reducing postoperative nausea and vomiting and the larger body of evidence from trials, these results support guideline recommendations for the routine use of dexamethasone.
    Otolaryngology Head and Neck Surgery 02/2014; 150(5). DOI:10.1177/0194599814521555 · 2.02 Impact Factor
  • Douglas C Barnhart · Jay G Berry · Rajendu Srivastava
    02/2014; 168(2):188-9. DOI:10.1001/jamapediatrics.2013.4700
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    ABSTRACT: To describe the quality of care for routine tonsillectomy at US children's hospitals. We conducted a retrospective cohort study of low-risk children undergoing same-day tonsillectomy between 2004 and 2010 at 36 US children's hospitals that submit data to the Pediatric Health Information System Database. We assessed quality of care by measuring evidence-based processes suggested by national guidelines, perioperative dexamethasone and no antibiotic use, and outcomes, 30-day tonsillectomy-related revisits to hospital. Of 139 715 children who underwent same-day tonsillectomy, 10 868 (7.8%) had a 30-day revisit to hospital. There was significant variability in the administration of dexamethasone (median 76.2%, range 0.3%-98.8%) and antibiotics (median 16.3%, range 2.7%-92.6%) across hospitals. The most common reasons for revisits were bleeding (3.0%) and vomiting and dehydration (2.2%). Older age (10-18 vs 1-3 years) was associated with a greater standardized risk of revisits for bleeding and a lower standardized risk of revisits for vomiting and dehydration. After standardizing for differences in patients and year of surgery, there was significant variability (P < .001) across hospitals in total revisits (median 7.8%, range 3.0%-12.6%), revisits for bleeding (median 3.0%, range 1.0%-8.8%), and revisits for vomiting and dehydration (median 1.9%, range 0.3%-4.4%). Substantial variation exists in the quality of care for routine tonsillectomy across US children's hospitals as measured by perioperative dexamethasone and antibiotic use and revisits to hospital. These data on evidence-based processes and relevant patient outcomes should be useful for hospitals' tonsillectomy quality improvement efforts.
    PEDIATRICS 02/2014; 133(2):280-8. DOI:10.1542/peds.2013-1884 · 5.47 Impact Factor

Publication Stats

1k Citations
355.92 Total Impact Points


  • 2005–2015
    • University of Utah
      • • Division of Pediatric Inpatient Medicine
      • • Department of Pediatrics
      Salt Lake City, Utah, United States
  • 2003–2007
    • Harvard University
      Cambridge, Massachusetts, United States
  • 2001–2006
    • Boston Children's Hospital
      Boston, Massachusetts, United States
    • Harvard Medical School
      • Department of Pediatrics
      Boston, Massachusetts, United States