Objectives: The objectives were to determine the frequency of administration of potentially inapp... more Objectives: The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage.
The American Heart Association&am... more The American Heart Association's (AHA's) Advanced Cardiac Life Support guidelines act as the national standards for termination of resuscitation (TOR) in cases of refractory out-of-hospital cardiac arrest. However, local emergency medical services (EMS) implementation of these guidelines has been nonuniform. To identify the operational issues within local EMS systems that may serve as barriers or facilitators to full acceptance of national guidelines for prehospital TOR in appropriate circumstances. Methods. We conducted three focus groups at the January 2008 National Association of EMS Physicians (NAEMSP) annual meeting. Snowball sampling was used to recruit 19 physicians, two EMS providers, one research director, one nurse, and one medical student attending the conference. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified three distinct stakeholder groups whose current beliefs and practices may influence local implementation of TOR: EMS providers with variations in education and work culture; EMS medical directors with responsibility but little authority; and online medical control physicians who do not communicate effectively with the other groups. Our focus group participants suggested that national organizations, such as the AHA and the American College of Emergency Physicians, may serve a role in overcoming the overarching barriers of communication, standardized educational requirements, and coordination of local services. We have identified operational barriers that may impede implementation of TOR guidelines. Three influential stakeholder groups will need to work with national organizations to overcome these local barriers.
When cardiac arrest occurs at home, family members are likely to be present during resuscitation ... more When cardiac arrest occurs at home, family members are likely to be present during resuscitation efforts. However, little training is provided to prehospital providers on how to best manage a family-witnessed resuscitation (FWR) and deliver the news of death in the field. To study the feasibility and utility of an educational intervention designed to improve prehospital provider comfort with FWR and death notification. This was a pilot study of a convenience sample of 45 prehospital providers who participated in an educational lecture, with 20 providers then attending a small-group standardized death-notification encounter. Descriptive statistics were calculated to assess pre- and postintervention attitudes and knowledge with respect to FWR and death notification. All subjects had participated in at least one cardiac arrest resuscitation effort, with 28 (62.2%) having performed a death notification. Seventy-one percent (n = 32) of the participants have continued resuscitation efforts despite futility because the family was present. Fifty-five percent of participants (n = 25) had an interest in improving their FWR and death notification skills. After the educational seminar, 61.2% (n = 19) of all participants correctly answered at least five of the six knowledge-based questions. The small-group intervention participants showed an overall improvement in death notification skills, with a majority expressing confidence in their ability to effectively communicate with families during an unsuccessful resuscitation. This pilot study suggests that a short educational intervention can impact prehospital providers' comfort with death notification. Future research will need to be conducted on prehospital provider skill retention and the impact this training has on family members.
As more efficient and value-based care models are sought for the US healthcare system, geographic... more As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. English language peer-reviewed publications on pediatric OU care in the United States. Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
To understand attitudes and self-reported practices of pediatric and general emergency physicians... more To understand attitudes and self-reported practices of pediatric and general emergency physicians regarding child passenger safety. We conducted a cross-sectional mailed national survey of 600 pediatric emergency medicine (PEM) physicians and 600 emergency medicine (EM) physicians who provide clinical care in the United States randomly sampled from the American Medical Association Physician Masterfile. Survey questions explored attitudes related to the role of the physician and the emergency department (ED) in child passenger safety and self-reported frequency of performing specific child passenger safety practices. Responses were received from 638 of 1000 (64%) eligible physicians with a valid mailing address. Surveys were completed by 367 PEM and 271 EM physicians. Regardless of their training background, emergency physicians overwhelmingly agreed that it is their role to educate parents about child passenger safety (95% PEM vs 82% EM) and that they can make a difference in how parents restrain their child (92% PEM vs 93% EM). Physicians were similar in their views that the most appropriate person to provide child passenger safety information in their ED was a nurse/midlevel provider followed by a physician. Self-report of child passenger safety practices in response to 2 hypothetical scenarios showed physicians infrequently provide best-practice safety recommendations to families. Emergency physicians are supportive of the ED as a setting to promote child passenger safety, yet do not consistently promote child passenger safety themselves. Differences between PEM and EM physicians' attitudes toward child passenger safety may necessitate different approaches on injury prevention in general and pediatric EDs.
Circulation: Cardiovascular Quality and Outcomes, 2009
Despite the existence of national American Heart Association guidelines and 2 termination-of-resu... more Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level. Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care. We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.
rule had a specificity of 0.987 (95% confidence interval (CI), 0.970-0.996) and a positive predic... more rule had a specificity of 0.987 (95% confidence interval (CI), 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.
To the best of the authors&am... more To the best of the authors' knowledge, admission of children under observation status in community hospitals has not been examined. The hypothesis of this study was that there has been an increase in observation charge code use over time and variations in the application of observation charge codes across hospital types. This was a cross-sectional analysis of 5 years (2007 through 2011) of administrative claims data from Michigan residents enrolled in Medicaid, Blue Cross/Blue Shield of Michigan preferred provider organization, and Blue Cross Network health maintenance organization compiled into a single data set. Emergency department (ED) visits to facilities in Michigan made by children (younger than 18 years) were selected. Observation-prone ED visits were identified based on the presence of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Counts of observation-prone ED visits were determined and descriptive statistics were calculated. Changes over time in the proportion of visits with observation charge codes by hospital type were assessed with chi-square analysis. The observation-prone ICD-9-CM codes were identified in 881,622 ED visits made by children to 142 Michigan facilities during the 5-year study period. Overall, the vast majority of visits (n = 646,499; 91.0%) with the selected ICD-9-CM codes resulted in discharge from the ED without associated observation or inpatient charge codes. Among the 64,288 visits that resulted in admission for observation or inpatient care, observation charge codes without inpatient charge codes were applied to 22,933 (35.7%) admissions, observation and inpatient charge codes were applied to 4,756 (7.4%) admissions, and inpatient charge codes without observation charge codes were applied to 36,599 (56.9%) admissions. Hospitals with pediatric ED and inpatient services (Type 1 and Type 2 hospitals) had higher proportions of ED visits that went on to admission for observation or inpatient care (15.9 and 10.7%) than hospitals without pediatric ED services (Type 3 and Type 4 hospitals; 7.2 and 3.7%). The proportion of admissions that had observation charge codes for all hospital types increased over time, most prominently among Type 1 and Type 2 hospitals. The application of observation charge codes to Michigan children with observation-prone conditions has increased over time across all hospital types. There is a need to evaluate pediatric observation care in diverse settings to compare the effectiveness of different models.
Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in... more Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in observation status, a billing designation for patients considered to need care that is less resource-intensive, and less expensive, than inpatient care. Observation status is also associated with lower hospital reimbursements and higher patient cost-sharing. The goal of this study was to examine resource utilization for treatment of envenomation under observation and inpatient status, and to compare patients in observation status receiving antivenom with all other patients in observation status. This was a retrospective study of patients with a primary diagnosis of toxic effect of venom seen during 2009 at 33 freestanding children's hospitals in the Pediatric Health Information System. Data on age, length of stay, adjusted costs (ratio cost to charges), ICU flags, and antivenom utilization were collected. Comparisons were conducted according to admission status (emergency department...
Driver distraction has been identified as a threat to individual drivers and public health. Motor... more Driver distraction has been identified as a threat to individual drivers and public health. Motor vehicle collisions remain a leading cause of death for children, yet little is known about distractions among drivers of children. This study sought to characterize potential distractions among drivers of children. A 2-site, cross-sectional, computerized survey of child passenger safety practices was conducted among adult drivers of 1- to 12-year-old children who presented for emergency care between October 2011 to May 2012. Drivers indicated the frequency with which they engaged in 10 potential distractions in the past month while driving with their child. Distractions were grouped in 4 categories: (1) nondriving, (2) cellular phone, (3) child, and (4) directions. Information about other unsafe driving behaviors and sociodemographic characteristics was collected. Nearly 90% of eligible parents participated. Analysis included 570 drivers (92.2%). Non-driving-related and cellular phone-related distractions were disclosed by >75% of participants. Fewer participants disclosed child (71.2%) and directions-related distractions (51.9%). Child age was associated with each distraction category. Cellular phone-related distractions were associated with the child riding daily in the family car, non-Hispanic white, and higher education. Parents admitting to drowsy driving and being pulled over for speeding had over 2 times higher odds of disclosing distractions from each category. Distracted driving activities are common among drivers of child passengers and are associated with other unsafe driving behaviors. Child passenger safety may be improved by preventing crash events through the reduction or elimination of distractions among drivers of child passengers.
Child restraint systems (CRS) are increasingly being designed to accommodate larger children and ... more Child restraint systems (CRS) are increasingly being designed to accommodate larger children and to mitigate side impact injuries. Little is known about the impact of CRS on the safety of other vehicle passengers due to limitations of existing crash databases. This study provides the first assessment of the seating positions occupied by child passengers and the relationship between CRS and other second-row passengers in a national sample of vehicles transporting children. A secondary analysis was conducted of data from the 2007-2009 National Survey of the Use of Booster Seats (NSUBS), a direct in-vehicle observational study of child passenger restraint use. Passengers riding in the same vehicle were identified and passenger position was determined. Vehicles with second-row child passengers were included in analyses of seat positions occupied by child passengers with and without CRS. Frequency counts for the different combinations of CRS and passengers in second rows were calculated. Of the 17,065 vehicles observed in 2007-2009 NSUBS, 14,506 (85%) vehicles contained at least 1 child passenger in a second row that contained no more than 3 total passengers. Of these 14,506 vehicles, 55 percent contained a lone child passenger in the second row. A CRS was in use in 4656 (59%) of the 7949 vehicles with a lone child passenger in the second row compared to 4077 (62%) of the 6557 vehicles with multiple passengers in the second row (P < .001). A passenger was adjacent to a CRS within 1333 (33%) of the 4077 vehicles containing a CRS in the second row. There were 3 second-row passengers in nearly 1 in 5 vehicles containing a CRS in the second row. Adults and children not using CRS are frequently seated in vehicle second rows adjacent to a child restrained in a CRS. These findings should be used to inform the regulation, design, and testing of CRS and to determine the risks of larger CRS designs to other passengers seated in the same vehicle row relative to the benefits of the CRS for the passenger it restrains.
Objective-To understand the association between neighborhood and individual characteristics in de... more Objective-To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA). 108 OHCA cases from Fulton County (Atlanta), Georgia were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.
OBJECTIVE-Brief hospitalizations for children may constitute an opportunity to provide care in an... more OBJECTIVE-Brief hospitalizations for children may constitute an opportunity to provide care in an alternative setting such as an observation unit. The goal of this study was to characterize recent national trends in brief inpatient stays for children in the United States.
Observed racial disparities in child safety seat use have not accounted for socioeconomic factors... more Observed racial disparities in child safety seat use have not accounted for socioeconomic factors. We hypothesized that racial differences in age-appropriate restraint use would be modified by socioeconomic status and child passenger safety information sources. A 2-site, cross-sectional tablet-based survey of parents seeking emergency care for their 1- to 12-year-old child was conducted between October 2011 and May 2012. Parents provided self-report of child passenger safety practices, demographic characteristics, and information sources. Direct observation of restraint use was conducted in a subset of children at emergency department discharge. Age-appropriate restraint use was defined by Michigan law. Of the 744 eligible parents, 669 agreed to participate and 601 provided complete responses to key variables. White parents reported higher use of car seats for 1- to 3-year-olds and booster seats for 4- to 7-year-olds compared with nonwhite parents. Regardless of race, <30% of 8- to 12-year-old children who were ≤4 feet, 9 inches tall used a booster seat. White parents had higher adjusted odds (3.86, 95% confidence interval 2.27-6.57) of reporting age-appropriate restraint use compared with nonwhite parents, controlling for education, income, information sources, and site. There was substantial agreement (82.6%, κ = 0.74) between parent report of their child's usual restraint and the observed restraint at emergency department discharge. Efforts should be directed at eliminating racial disparities in age-appropriate child passenger restraint use for children <8 years. Booster seat use, seat belt use, and rear seating represent opportunities to improve child passenger safety practices among older children.
Pediatric observation units provide an alternative to traditional hospitalization. The extent to ... more Pediatric observation units provide an alternative to traditional hospitalization. The extent to which observation units could replace inpatient care for asthmatic children is unknown. To describe brief inpatient ("high-turnover," HTO) stays for US children hospitalized with a principal discharge diagnosis of asthma, to characterize cases that may be appropriate for observation. We analyzed the 2006 Kids' Inpatient Database, a nationally representative sample of hospital discharges. HTO stays were defined as hospitalizations of 0 or 1 night in duration. We conducted descriptive statistics and case-mix adjusted, sample-weighted regression analysis of HTO stays, and associated hospital charges. Discharges among children aged 2 to 20 years with a principal discharge diagnosis of asthma. HTO stays and total charges. Overall, 34,592 (34%) pediatric asthma hospitalizations were HTO, accounting for 66,278 hospital days in 2006. HTO stays were associated with younger age, uncomplicated asthma, and private insurance. Freestanding children's hospitals had the highest proportion of HTO stays, 38% (95% CI: 34%-42%) compared with 32% (95% CI: 28%-36%) for children's units and 33% (95% CI: 31%-34%) for general hospitals. In multivariate regression analyses, charges were significantly higher across hospital types when HTO stays begin in the emergency department. The presence of a large number of HTO stays for children hospitalized for asthma suggests the need to explore opportunities to restructure care for this condition, perhaps through the development of physically or operationally distinct observation units.
BACKGROUND AND OBJECTIVE:Child health is influenced by biomedical and socioeconomic factors. Few ... more BACKGROUND AND OBJECTIVE:Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI).METHODS:Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups.RESULTS:From 116 636 hospitalizations, 4 of 5 co...
Objectives: The objectives were to determine the frequency of administration of potentially inapp... more Objectives: The objectives were to determine the frequency of administration of potentially inappropriate medications (PIMs) to older emergency department (ED) patients and to examine recent trends in the rates of PIM usage.
The American Heart Association&am... more The American Heart Association's (AHA's) Advanced Cardiac Life Support guidelines act as the national standards for termination of resuscitation (TOR) in cases of refractory out-of-hospital cardiac arrest. However, local emergency medical services (EMS) implementation of these guidelines has been nonuniform. To identify the operational issues within local EMS systems that may serve as barriers or facilitators to full acceptance of national guidelines for prehospital TOR in appropriate circumstances. Methods. We conducted three focus groups at the January 2008 National Association of EMS Physicians (NAEMSP) annual meeting. Snowball sampling was used to recruit 19 physicians, two EMS providers, one research director, one nurse, and one medical student attending the conference. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified three distinct stakeholder groups whose current beliefs and practices may influence local implementation of TOR: EMS providers with variations in education and work culture; EMS medical directors with responsibility but little authority; and online medical control physicians who do not communicate effectively with the other groups. Our focus group participants suggested that national organizations, such as the AHA and the American College of Emergency Physicians, may serve a role in overcoming the overarching barriers of communication, standardized educational requirements, and coordination of local services. We have identified operational barriers that may impede implementation of TOR guidelines. Three influential stakeholder groups will need to work with national organizations to overcome these local barriers.
When cardiac arrest occurs at home, family members are likely to be present during resuscitation ... more When cardiac arrest occurs at home, family members are likely to be present during resuscitation efforts. However, little training is provided to prehospital providers on how to best manage a family-witnessed resuscitation (FWR) and deliver the news of death in the field. To study the feasibility and utility of an educational intervention designed to improve prehospital provider comfort with FWR and death notification. This was a pilot study of a convenience sample of 45 prehospital providers who participated in an educational lecture, with 20 providers then attending a small-group standardized death-notification encounter. Descriptive statistics were calculated to assess pre- and postintervention attitudes and knowledge with respect to FWR and death notification. All subjects had participated in at least one cardiac arrest resuscitation effort, with 28 (62.2%) having performed a death notification. Seventy-one percent (n = 32) of the participants have continued resuscitation efforts despite futility because the family was present. Fifty-five percent of participants (n = 25) had an interest in improving their FWR and death notification skills. After the educational seminar, 61.2% (n = 19) of all participants correctly answered at least five of the six knowledge-based questions. The small-group intervention participants showed an overall improvement in death notification skills, with a majority expressing confidence in their ability to effectively communicate with families during an unsuccessful resuscitation. This pilot study suggests that a short educational intervention can impact prehospital providers' comfort with death notification. Future research will need to be conducted on prehospital provider skill retention and the impact this training has on family members.
As more efficient and value-based care models are sought for the US healthcare system, geographic... more As more efficient and value-based care models are sought for the US healthcare system, geographically distinct observation units (OUs) may become an integral part of hospital-based care for children. To systematically review the literature and evaluate the structure and function of pediatric OUs in the United States. Searches were conducted in Medline, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Health Care Advisory Board (HCAB), Lexis-Nexis, National Guideline Clearinghouse, and Cochrane Reviews, through February 2009, with review of select bibliographies. English language peer-reviewed publications on pediatric OU care in the United States. Two authors independently determined study eligibility. Studies were graded using a 5-level quality assessment tool. Data were extracted using a standardized form. A total of 21 studies met inclusion criteria: 2 randomized trials, 2 prospective observational, 12 retrospective cohort, 2 before and after, and 3 descriptive studies. Studies present data on more than 22,000 children cared for in OUs, most at large academic centers. This systematic review provides a descriptive overview of the structure and function of pediatric OUs in the United States. Despite seemingly straightforward outcomes for OU care, significant heterogeneity in the reporting of length of stay, admission rates, return visit rates, and costs precluded our ability to conduct meta-analyses. We propose standard outcome measures and future directions for pediatric OU research. Future research using consistent outcome measures will be critical to determining whether OUs can improve the quality and cost of providing care to children requiring observation-length stays.
To understand attitudes and self-reported practices of pediatric and general emergency physicians... more To understand attitudes and self-reported practices of pediatric and general emergency physicians regarding child passenger safety. We conducted a cross-sectional mailed national survey of 600 pediatric emergency medicine (PEM) physicians and 600 emergency medicine (EM) physicians who provide clinical care in the United States randomly sampled from the American Medical Association Physician Masterfile. Survey questions explored attitudes related to the role of the physician and the emergency department (ED) in child passenger safety and self-reported frequency of performing specific child passenger safety practices. Responses were received from 638 of 1000 (64%) eligible physicians with a valid mailing address. Surveys were completed by 367 PEM and 271 EM physicians. Regardless of their training background, emergency physicians overwhelmingly agreed that it is their role to educate parents about child passenger safety (95% PEM vs 82% EM) and that they can make a difference in how parents restrain their child (92% PEM vs 93% EM). Physicians were similar in their views that the most appropriate person to provide child passenger safety information in their ED was a nurse/midlevel provider followed by a physician. Self-report of child passenger safety practices in response to 2 hypothetical scenarios showed physicians infrequently provide best-practice safety recommendations to families. Emergency physicians are supportive of the ED as a setting to promote child passenger safety, yet do not consistently promote child passenger safety themselves. Differences between PEM and EM physicians' attitudes toward child passenger safety may necessitate different approaches on injury prevention in general and pediatric EDs.
Circulation: Cardiovascular Quality and Outcomes, 2009
Despite the existence of national American Heart Association guidelines and 2 termination-of-resu... more Despite the existence of national American Heart Association guidelines and 2 termination-of-resuscitation (TOR) rules for ceasing efforts in refractory out-of-hospital cardiac arrest, many emergency medical services agencies in the United States have adopted their own local protocols. Public policies and local perceptions may serve as barriers or facilitators to implementing national TOR guidelines at the local level. Three focus groups, lasting 90 to 120 minutes, were conducted at the National Association of Emergency Medical Services Physicians meeting in January 2008. Snowball sampling was used to recruit participants. Two reviewers analyzed the data in an iterative process to identify recurrent and unifying themes. We identified 3 distinct groups whose current policies or perceptions may impede efforts to adopt national TOR guidelines: payers who incentivize transport; legislators who create state mandates for transport and allow only narrow use of do-not-resuscitate orders; and communities where cultural norms are perceived to impede termination of resuscitation. Our participants suggested that national organizations, such as the American Heart Association and American College of Emergency Physicians, may serve as potential facilitators in addressing these barriers by taking the lead in asking payers to change reimbursement structures; encouraging legislators to revise laws to reflect the best available medical evidence; and educating the public that rapid transport to the hospital cannot substitute for optimal provision of prehospital care. We have identified 3 influential groups who will need to work with national organizations to overcome current policies or prevailing perceptions that may impede implementing national TOR guidelines.
rule had a specificity of 0.987 (95% confidence interval (CI), 0.970-0.996) and a positive predic... more rule had a specificity of 0.987 (95% confidence interval (CI), 0.970-0.996) and a positive predictive value of 0.998 (95% CI, 0.996-0.999) for predicting lack of survival. The ALS rule had a specificity of 1.000 (95% CI, 0.991-1.000) and positive predictive value of 1.000 (95% CI, 0.997-1.000) for predicting lack of survival.
To the best of the authors&am... more To the best of the authors' knowledge, admission of children under observation status in community hospitals has not been examined. The hypothesis of this study was that there has been an increase in observation charge code use over time and variations in the application of observation charge codes across hospital types. This was a cross-sectional analysis of 5 years (2007 through 2011) of administrative claims data from Michigan residents enrolled in Medicaid, Blue Cross/Blue Shield of Michigan preferred provider organization, and Blue Cross Network health maintenance organization compiled into a single data set. Emergency department (ED) visits to facilities in Michigan made by children (younger than 18 years) were selected. Observation-prone ED visits were identified based on the presence of International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Counts of observation-prone ED visits were determined and descriptive statistics were calculated. Changes over time in the proportion of visits with observation charge codes by hospital type were assessed with chi-square analysis. The observation-prone ICD-9-CM codes were identified in 881,622 ED visits made by children to 142 Michigan facilities during the 5-year study period. Overall, the vast majority of visits (n = 646,499; 91.0%) with the selected ICD-9-CM codes resulted in discharge from the ED without associated observation or inpatient charge codes. Among the 64,288 visits that resulted in admission for observation or inpatient care, observation charge codes without inpatient charge codes were applied to 22,933 (35.7%) admissions, observation and inpatient charge codes were applied to 4,756 (7.4%) admissions, and inpatient charge codes without observation charge codes were applied to 36,599 (56.9%) admissions. Hospitals with pediatric ED and inpatient services (Type 1 and Type 2 hospitals) had higher proportions of ED visits that went on to admission for observation or inpatient care (15.9 and 10.7%) than hospitals without pediatric ED services (Type 3 and Type 4 hospitals; 7.2 and 3.7%). The proportion of admissions that had observation charge codes for all hospital types increased over time, most prominently among Type 1 and Type 2 hospitals. The application of observation charge codes to Michigan children with observation-prone conditions has increased over time across all hospital types. There is a need to evaluate pediatric observation care in diverse settings to compare the effectiveness of different models.
Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in... more Treating envenomation with antivenom is costly. Many patients being treated with antivenom are in observation status, a billing designation for patients considered to need care that is less resource-intensive, and less expensive, than inpatient care. Observation status is also associated with lower hospital reimbursements and higher patient cost-sharing. The goal of this study was to examine resource utilization for treatment of envenomation under observation and inpatient status, and to compare patients in observation status receiving antivenom with all other patients in observation status. This was a retrospective study of patients with a primary diagnosis of toxic effect of venom seen during 2009 at 33 freestanding children's hospitals in the Pediatric Health Information System. Data on age, length of stay, adjusted costs (ratio cost to charges), ICU flags, and antivenom utilization were collected. Comparisons were conducted according to admission status (emergency department...
Driver distraction has been identified as a threat to individual drivers and public health. Motor... more Driver distraction has been identified as a threat to individual drivers and public health. Motor vehicle collisions remain a leading cause of death for children, yet little is known about distractions among drivers of children. This study sought to characterize potential distractions among drivers of children. A 2-site, cross-sectional, computerized survey of child passenger safety practices was conducted among adult drivers of 1- to 12-year-old children who presented for emergency care between October 2011 to May 2012. Drivers indicated the frequency with which they engaged in 10 potential distractions in the past month while driving with their child. Distractions were grouped in 4 categories: (1) nondriving, (2) cellular phone, (3) child, and (4) directions. Information about other unsafe driving behaviors and sociodemographic characteristics was collected. Nearly 90% of eligible parents participated. Analysis included 570 drivers (92.2%). Non-driving-related and cellular phone-related distractions were disclosed by >75% of participants. Fewer participants disclosed child (71.2%) and directions-related distractions (51.9%). Child age was associated with each distraction category. Cellular phone-related distractions were associated with the child riding daily in the family car, non-Hispanic white, and higher education. Parents admitting to drowsy driving and being pulled over for speeding had over 2 times higher odds of disclosing distractions from each category. Distracted driving activities are common among drivers of child passengers and are associated with other unsafe driving behaviors. Child passenger safety may be improved by preventing crash events through the reduction or elimination of distractions among drivers of child passengers.
Child restraint systems (CRS) are increasingly being designed to accommodate larger children and ... more Child restraint systems (CRS) are increasingly being designed to accommodate larger children and to mitigate side impact injuries. Little is known about the impact of CRS on the safety of other vehicle passengers due to limitations of existing crash databases. This study provides the first assessment of the seating positions occupied by child passengers and the relationship between CRS and other second-row passengers in a national sample of vehicles transporting children. A secondary analysis was conducted of data from the 2007-2009 National Survey of the Use of Booster Seats (NSUBS), a direct in-vehicle observational study of child passenger restraint use. Passengers riding in the same vehicle were identified and passenger position was determined. Vehicles with second-row child passengers were included in analyses of seat positions occupied by child passengers with and without CRS. Frequency counts for the different combinations of CRS and passengers in second rows were calculated. Of the 17,065 vehicles observed in 2007-2009 NSUBS, 14,506 (85%) vehicles contained at least 1 child passenger in a second row that contained no more than 3 total passengers. Of these 14,506 vehicles, 55 percent contained a lone child passenger in the second row. A CRS was in use in 4656 (59%) of the 7949 vehicles with a lone child passenger in the second row compared to 4077 (62%) of the 6557 vehicles with multiple passengers in the second row (P < .001). A passenger was adjacent to a CRS within 1333 (33%) of the 4077 vehicles containing a CRS in the second row. There were 3 second-row passengers in nearly 1 in 5 vehicles containing a CRS in the second row. Adults and children not using CRS are frequently seated in vehicle second rows adjacent to a child restrained in a CRS. These findings should be used to inform the regulation, design, and testing of CRS and to determine the risks of larger CRS designs to other passengers seated in the same vehicle row relative to the benefits of the CRS for the passenger it restrains.
Objective-To understand the association between neighborhood and individual characteristics in de... more Objective-To understand the association between neighborhood and individual characteristics in determining whether or not bystanders perform cardiopulmonary resuscitation (CPR) in cases of out-of-hospital cardiac arrest (OHCA). 108 OHCA cases from Fulton County (Atlanta), Georgia were eligible for bystander CPR. We conducted multi-level non-linear regression analysis and derived Empirical Bayes estimates for bystander CPR by census tract.
OBJECTIVE-Brief hospitalizations for children may constitute an opportunity to provide care in an... more OBJECTIVE-Brief hospitalizations for children may constitute an opportunity to provide care in an alternative setting such as an observation unit. The goal of this study was to characterize recent national trends in brief inpatient stays for children in the United States.
Observed racial disparities in child safety seat use have not accounted for socioeconomic factors... more Observed racial disparities in child safety seat use have not accounted for socioeconomic factors. We hypothesized that racial differences in age-appropriate restraint use would be modified by socioeconomic status and child passenger safety information sources. A 2-site, cross-sectional tablet-based survey of parents seeking emergency care for their 1- to 12-year-old child was conducted between October 2011 and May 2012. Parents provided self-report of child passenger safety practices, demographic characteristics, and information sources. Direct observation of restraint use was conducted in a subset of children at emergency department discharge. Age-appropriate restraint use was defined by Michigan law. Of the 744 eligible parents, 669 agreed to participate and 601 provided complete responses to key variables. White parents reported higher use of car seats for 1- to 3-year-olds and booster seats for 4- to 7-year-olds compared with nonwhite parents. Regardless of race, <30% of 8- to 12-year-old children who were ≤4 feet, 9 inches tall used a booster seat. White parents had higher adjusted odds (3.86, 95% confidence interval 2.27-6.57) of reporting age-appropriate restraint use compared with nonwhite parents, controlling for education, income, information sources, and site. There was substantial agreement (82.6%, κ = 0.74) between parent report of their child's usual restraint and the observed restraint at emergency department discharge. Efforts should be directed at eliminating racial disparities in age-appropriate child passenger restraint use for children <8 years. Booster seat use, seat belt use, and rear seating represent opportunities to improve child passenger safety practices among older children.
Pediatric observation units provide an alternative to traditional hospitalization. The extent to ... more Pediatric observation units provide an alternative to traditional hospitalization. The extent to which observation units could replace inpatient care for asthmatic children is unknown. To describe brief inpatient ("high-turnover," HTO) stays for US children hospitalized with a principal discharge diagnosis of asthma, to characterize cases that may be appropriate for observation. We analyzed the 2006 Kids' Inpatient Database, a nationally representative sample of hospital discharges. HTO stays were defined as hospitalizations of 0 or 1 night in duration. We conducted descriptive statistics and case-mix adjusted, sample-weighted regression analysis of HTO stays, and associated hospital charges. Discharges among children aged 2 to 20 years with a principal discharge diagnosis of asthma. HTO stays and total charges. Overall, 34,592 (34%) pediatric asthma hospitalizations were HTO, accounting for 66,278 hospital days in 2006. HTO stays were associated with younger age, uncomplicated asthma, and private insurance. Freestanding children's hospitals had the highest proportion of HTO stays, 38% (95% CI: 34%-42%) compared with 32% (95% CI: 28%-36%) for children's units and 33% (95% CI: 31%-34%) for general hospitals. In multivariate regression analyses, charges were significantly higher across hospital types when HTO stays begin in the emergency department. The presence of a large number of HTO stays for children hospitalized for asthma suggests the need to explore opportunities to restructure care for this condition, perhaps through the development of physically or operationally distinct observation units.
BACKGROUND AND OBJECTIVE:Child health is influenced by biomedical and socioeconomic factors. Few ... more BACKGROUND AND OBJECTIVE:Child health is influenced by biomedical and socioeconomic factors. Few studies have explored the relationship between community-level income and inpatient resource utilization for children. Our objective was to analyze inpatient costs for children hospitalized with common conditions in relation to zip code-based median annual household income (HHI).METHODS:Retrospective national cohort from 32 freestanding children's hospitals for asthma, diabetes, bronchiolitis and respiratory syncytial virus, pneumonia, and kidney and urinary tract infections. Standardized cost of care for individual hospitalizations and across hospitalizations for the same patient and condition were modeled by using mixed-effects methods, adjusting for severity of illness, age, gender, and race. Main exposure was median annual HHI. Posthoc tests compared adjusted standardized costs for patients from the lowest and highest income groups.RESULTS:From 116 636 hospitalizations, 4 of 5 co...
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Papers by Michelle Macy