Patient‐level Factors and the Quality of Care Delivered in Pediatric Emergency Departments

Objective

Quality of care delivered to adult patients in the emergency department (ED) is often associated with demographic and clinical factors such as a patient's race/ethnicity and insurance status. We sought to determine whether the quality of care delivered to children in the ED was associated with a variety of patient‐level factors.

Methods

This was a retrospective, observational cohort study. Pediatric patients (<18 years) who received care between January 2011 and December 2011 at one of 12 EDs participating in the Pediatric Emergency Care Applied Research Network (PECARN) were included. We analyzed demographic factors (including age, sex, and payment source) and clinical factors (including triage, chief complaint, and severity of illness). We measured quality of care using a previously validated implicit review instrument using chart review with a summary score that ranged from 5 to 35. We examined associations between demographic and clinical factors and quality of care using a hierarchical multivariable linear regression model with hospital site as a random effect.

Results

In the multivariable model, among the 620 ED encounters reviewed, we did not find any association between patient age, sex, race/ethnicity, and payment source and the quality of care delivered. However, we did find that some chief complaint categories were significantly associated with lower than average quality of care, including fever (–0.65 points in quality, 95% confidence interval [CI] = –1.24 to –0.06) and upper respiratory symptoms (–0.68 points in quality, 95% CI = –1.30 to –0.07).

Conclusion

We found that quality of ED care delivered to children among a cohort of 12 EDs participating in the PECARN was high and did not differ by patient age, sex, race/ethnicity, and payment source, but did vary by the presenting chief complaint.

     

A critical assessment of early warning score records in 168,000 patients

The national early warning score (NEWS) is recommended to detect deterioration in hospitalised patients. In 2013, a NEWS-based system was introduced in a hospital service with over 250,000 annual admissions, generating large amounts of NEWS data. The quality of such data has not been described. We critically assessed NEWS data recorded over 12 months. This observational study included NEWS records from adult inpatients hospitalized in the Capital Region of Denmark during 2014. Physiological variables and the use of supplementary oxygen (NEWS variables) were recorded. We identified implausible records and assessed the distributions of NEWS variable values. Of 2,835,331 NEWS records, 271,103 (10%) were incomplete with one or more variable missing and 0.2% of records containing implausible values. Digit preferences were identified for respiratory rate, supplementation oxygen flow, pulse rate, and systolic blood pressure. There was an accumulation of pulse rate records below 91 beats per minute. Among complete NEWS records, 64% had NEWS?≥?1; 29% had NEWS?≥?3; and 8% had NEWS?≥?6. In a large set of NEWS data, 10% of the records were incomplete. In a system where data were manually entered into an electronic medical record, digit preferences and the accumulation of pulse rate records below 91 beats per minute, which is the limit for NEWS point generation, showed that staff practice influenced the recorded values. This indicates a potential limitation of transferability of research results obtained in such systems to fully automated systems.     

Assessing Organizational Change in Multisector Community Health Alliances

Objective

The purpose of this article was to identify some common organizational features of multisector health care alliances (MHCAs) and the analytic challenges presented by those characteristics in assessing organizational change.

Data Sources

Two rounds of an Internet-based survey of participants in 14 MHCAs.

Study Design

We highlight three analytic challenges that can arise when quantitatively studying the organizational characteristics of MHCAs—assessing change in MHCA organization, assessment of construct reliability, and aggregation of individual responses to reflect organizational characteristics. We illustrate these issues using a leadership effectiveness scale (12 items) validated in previous research and data from 14 MHCAs participating in the Robert Wood Johnson Foundation''s Aligning Forces for Quality (AF4Q) program.

Findings

High levels of instability and turnover in MHCA membership create challenges in using survey data to study changes in key organizational characteristics of MHCAs. We offer several recommendations to diagnose the source and extent of these problems.     

Adoption of Electronic Medical Record-Based Decision Support for Otitis Media in Children

ObjectiveSubstantial investment in electronic health records (EHRs) has provided an unprecedented opportunity to use clinical decision support (CDS) to increase guideline adherence. To inform efforts to maximize adoption, we characterized the adoption of an otitis media (OM) CDS system, the impact of performance feedback on adoption, and the effects of adoption on guideline adherence.ConclusionsPerformance feedback increased CDS adoption, but additional strategies are needed to integrate CDS into primary care workflows.     

A multimedia consent tool for research participants in the Gambia: a randomized controlled trial

ObjectiveTo assess the effectiveness of a multimedia informed consent tool for adults participating in a clinical trial in the Gambia.MethodsAdults eligible for inclusion in a malaria treatment trial (n = 311) were randomized to receive information needed for informed consent using either a multimedia tool (intervention arm) or a standard procedure (control arm). A computerized, audio questionnaire was used to assess participants’ comprehension of informed consent. This was done immediately after consent had been obtained (at day 0) and at subsequent follow-up visits (days 7, 14, 21 and 28). The acceptability and ease of use of the multimedia tool were assessed in focus groups.FindingsOn day 0, the median comprehension score in the intervention arm was 64% compared with 40% in the control arm (P = 0.042). The difference remained significant at all follow-up visits. Poorer comprehension was independently associated with female sex (odds ratio, OR: 0.29; 95% confidence interval, CI: 0.12–0.70) and residing in Jahaly rather than Basse province (OR: 0.33; 95% CI: 0.13–0.82). There was no significant independent association with educational level. The risk that a participant’s comprehension score would drop to half of the initial value was lower in the intervention arm (hazard ratio 0.22, 95% CI: 0.16–0.31). Overall, 70% (42/60) of focus group participants from the intervention arm found the multimedia tool clear and easy to understand.ConclusionA multimedia informed consent tool significantly improved comprehension and retention of consent information by research participants with low levels of literacy.     

High Alcohol Concentration Products Associated With Poverty and State Alcohol Policies

Objectives. We examined the associations among zip code demographics, the state alcohol policy environment, and the retail outlet availability of multiple fruit-flavored alcoholic drinks in a can (MFAC).Methods. In a nationally representative sample of zip codes (n = 872), we merged data from 4 sources: publicly available marketing information from 2 major MFAC producers, the US Census Bureau, state alcohol regulatory agencies, and recent research on state alcohol policies. We used zero-inflated negative binomial regression models to examine MFAC outlet availability in the United States.Results. More than 98% of MFAC outlets were off-premises alcohol establishments. After we controlled for population size and the number of licensed on- and off-premises alcohol outlets within zip codes, more families below the poverty line and weaker state alcohol control policies were associated with greater MFAC outlet availability.Conclusions. Economic conditions and alcohol policy environment appeared to be related to MFAC outlet availability, after adjusting for the general availability of alcohol. Research is needed to determine whether MFACs are disproportionately contributing to alcohol-related harm in socially and economically disadvantaged communities. Policies to better regulate the off-premises sale of alcohol are needed.In 2003, the first premixed caffeinated alcohol product was introduced in the United States, and by 2010 at least 8 brands of caffeinated alcohol were being sold.1,2 Released in August 2008, Four Loko became the most popular of these ready-to-drink products among underage drinkers.3,4 Anecdotal news and scientific reports linked Four Loko consumption to a number of dangerous drinking episodes, and as a result, questions were raised about its safety.5–7In addition to gaining the attention of the attorney generals of several states,8 by 2010, an emerging body of research began to show that caffeine–alcohol co-ingestion could produce elevated intoxication levels and reduce perceptions of impairment, and that drinkers could engage in riskier behaviors compared with the consumption of alcohol alone.9–14 Based on this research, the Federal Trade Commission and the Food and Drug Administration concluded that the combined high alcohol and high caffeine content of these premixed products was likely causing consumer harm.1,15 In response to pressure from the government, producers of products such as Four Loko and Joose voluntarily ceased production of these caffeinated drinks in November 2010.3 However, shortly thereafter, these producers began distributing reformulated products that no longer contained caffeine, guarine, and taurine.3,16,17Although the presence of a significant amount of caffeine likely played a role in producing injury and death, other characteristics of these products also likely contributed to hazardous alcohol consumption.18 Namely, their exceptionally high alcohol content, low price, fruit flavoring, colorful packaging, and targeted marketing may be responsible for attracting underage and lower socioeconomic consumers, and may continue to contribute to high-risk drinking among these groups.18,19 The combination of these product features led to Four Loko, Joose, and other similar beverages being labeled as multiple fruit-flavored alcoholic drinks in a can (MFAC) or supersized alcopops. Although alcopops contain similar fruit flavoring, MFACs are packaged in large, single-serving cans rather than in multiunit packs, they have higher alcohol content, and they cost less per standard drink, distinguishing them from alcopops.18 MFAC products are typically high in alcohol concentration (12%) and combined with large-sized containers (23.5 fluid ounces) result in that a single container, which is typically consumed immediately as 1 drink, actually contains 5 standard drinks.18 Moreover, the typical price is only $2.50 to $3.00, representing one of the lowest costs per dose of alcohol.18,19 There is limited research on MFAC products. Drug Abuse Warning Network data20 indicated that, in 2010, when Four Loko was primarily sold as a caffeinated product, there were an estimated 1242 hospital emergency department visits in the United States by persons who had consumed Four Loko (95% confidence interval = 332, 2152).21 However, in 2011, the first year Four Loko was sold without caffeine, the estimated Four Loko–related emergency department visits increased by nearly 4.5 times, to a total of 5492 (95% confidence interval = 2925, 8059).21 This substantial increase in emergency department visits suggests that Four Loko continues to be a health threat, despite the removal of caffeine. However, Four Loko was the only MFAC brand reported by the Drug Abuse Warning Network. Furthermore, a national survey conducted in 2012 found that approximately 6% of underaged drinkers consumed a Four Loko in the past 30 days, whereas consumption of other MFACs (e.g., Blast, Sparks, and Tilt) was less common.4Even less is known about the marketing and retail availability of MFAC products. One important question is whether the potential harms associated with MFAC consumption are borne evenly by all segments of society. The targeted marketing of potentially harmful products to vulnerable populations (e.g., low-income minority communities and communities with high proportions of youths) raises ethical concerns about social justice and corporate social responsibility.22Our purpose in this study was to test 2 hypotheses about MFAC outlet availability in the United States. First, we expected to find that zip code areas in states with stronger alcohol control environments (i.e., more laws, regulations, and practices designed to reduce excessive alcohol use and related harm) would have less MFAC availability. We expected this association because the combined effects of multiple concurrent alcohol policies in an overall alcohol policy environment helps shape local norms regarding alcohol use. For example, harsh penalties for supplying alcohol to underage drinkers or using or accepting fake identification may influence local alcohol marketing practices (i.e., products presumed to be higher risk might not be as heavily supplied or demanded in such areas). Second, we anticipated that zip code areas with greater poverty and a larger concentration of racial/ethnic minority persons would have greater MFAC outlet availability. The relatively low price of MFACs might make the products particularly appealing to economically disadvantaged communities.18,19 This notion was supported by previous research on malt liquor, another low-price, high-alcohol content, ready-to-drink product that was heavily marketed to and had greater retail availability in low-income minority communities.23–25 However, to date, there has been no systematic inquiry into these concerns with regard to MFAC products.     

Vital Signs: Estimated Effects of a Coordinated Approach for Action to Reduce Antibiotic-Resistant Infections in Health Care Facilities — United States

BackgroundTreatments for health care–associated infections (HAIs) caused by antibiotic-resistant bacteria and Clostridium difficile are limited, and some patients have developed untreatable infections. Evidence-supported interventions are available, but coordinated approaches to interrupt the spread of HAIs could have a greater impact on reversing the increasing incidence of these infections than independent facility-based program efforts.MethodsData from CDC’s National Healthcare Safety Network and Emerging Infections Program were analyzed to project the number of health care–associated infections from antibiotic-resistant bacteria or C. difficile both with and without a large scale national intervention that would include interrupting transmission and improved antibiotic stewardship. As an example, the impact of reducing transmission of one antibiotic-resistant infection (carbapenem-resistant Enterobacteriaceae [CRE]) on cumulative prevalence and number of HAI transmission events within interconnected groups of health care facilities was modeled using two distinct approaches, a large scale and a smaller scale health care network.ResultsImmediate nationwide infection control and antibiotic stewardship interventions, over 5 years, could avert an estimated 619,000 HAIs resulting from CRE, multidrug-resistant Pseudomonas aeruginosa, invasive methicillin-resistant Staphylococcus aureus (MRSA), or C. difficile. Compared with independent efforts, a coordinated response to prevent CRE spread across a group of inter-connected health care facilities resulted in a cumulative 74% reduction in acquisitions over 5 years in a 10-facility network model, and 55% reduction over 15 years in a 102-facility network model.ConclusionsWith effective action now, more than half a million antibiotic-resistant health care–associated infections could be prevented over 5 years. Models representing both large and small groups of interconnected health care facilities illustrate that a coordinated approach to interrupting transmission is more effective than historical independent facility-based efforts.Implications for Public HealthPublic health–led coordinated prevention approaches have the potential to more completely address the emergence and dissemination of these antibiotic-resistant organisms and C. difficile than independent facility–based efforts.